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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411142
Report Date: 10/27/2023
Date Signed: 10/27/2023 02:33:32 PM


Document Has Been Signed on 10/27/2023 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:CEBALLOS, DORAFACILITY NUMBER:
434411142
ADMINISTRATOR:CEBALLOS, DORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 876-3794
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:14CENSUS: 7DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Dora CeballosTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee's brother Rogelio Ceballos for a required one year visit. LPA explained the nature of today’s inspection to him. Rogelio stated his sister had just left for a doctors appointment. Present were licensee's brother and seven day care children. LPA observed one infant and five toddlers and one kindergarten child. Days and hours of operation are Monday to Friday, 7:00am to 5:30pm. The adults that reside in the home are licensee and her brother.

A review of staff records on 10/16/2023 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee's brother Rogelio Ceballos was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.


LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed a barricaded fireplace and two wall heaters that are connected. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed razors, beauty products, shampoos, conditioners and soaps accessible to children in the bathroom. LPA observed a fully charged 3A40BC fire extinguisher, a working smoke and carbon monoxide detector. Licensee's brother states there are no weapons/firearms in the home. Off limit areas indoor: three bedrooms and attached garage. There are no bodies of water. Backyard is fenced. Off limits outdoor: fenced off area surrounding the play area for children including a storage. LPA observed one dog in the home and licensee's brother states dog is vaccinated. LPA
SUPERVISOR'S NAME: Susy CervantesTELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CEBALLOS, DORA
FACILITY NUMBER: 434411142
VISIT DATE: 10/27/2023
NARRATIVE
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observed licensee and her brother do not have a current CPR and First Aid certification. Licensee’s expires 08/14/2023 and her brother's on 10/10/2023. LPA did not observe a completed Mandated Reporter training certificate for licensee and her brother. LPA observed last fire drill was conducted on 03/17/2023.

Licensee's brother was unable to find children's files. LPA observed a current roster. Licensee's brother did not have a Safe Sleep log for infant in care. An Annual Continuation Visit will be conducted to complete report.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee's brother was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPA Deanna Villagrana informed licensee's brother Rogelio Ceballos that this report dated 10/27/2023 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Deanna Villagrana informed the licensee's brother Rogelio Ceballos to provide a copy of this licensing report dated 10/27/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Susy CervantesTELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/27/2023 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: CEBALLOS, DORA
FACILITY NUMBER: 434411142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA observed last fire drill was conducted on 03/17/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee will conduct a fire drill and submit updated log to CCLD by POC date.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA did not observe a completed Mandated Reporter training certificate for licensee and her brother which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee will submit updated Mandated Reporter Certificates for her and her brother to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Susy CervantesTELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 10/27/2023 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: CEBALLOS, DORA
FACILITY NUMBER: 434411142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA observed licensee and her brother do not have a current CPR and First Aid certification. Licensee’s expires 08/14/2023 and her brother's on 10/10/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee will submit a current CPR/1st Aid certificate for herself and her brother to CCLD by POC date.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Licensee's brother did not have a Safe Sleep log for infant in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee will submit a Safe Sleep log for infant in care for week 10/30/2023-11/03/2023 to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Susy CervantesTELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/27/2023 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: CEBALLOS, DORA
FACILITY NUMBER: 434411142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)


This requirement is not met as evidenced by: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed razors, beauty products, shampoos, conditioners and soaps accessible to children in the bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2023
Plan of Correction
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Licensee will submit photos of all items removed in the bathroom to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Susy CervantesTELEPHONE: (408) -32-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5