434411371-7-11-2019-07-CC-MSMS-BDYQK7-20190711121351

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411371
Report Date: 07/11/2019
Date Signed: 07/11/2019 12:13:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	ROSALES, MARY JANE		FACILITY NUMBER:	434411371
ADMINISTRATOR:	ROSALES, MARY JANE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 769-4546
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94089
CAPACITY:	14	CENSUS: 3	DATE:	07/11/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Mary Jane Rosales		TIME COMPLETED:	12:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mel Matos met with Mary Jane Rosales, Licensee, for an unannounced annual/random inspection. LPA notes that the entrance to the day care is via the right side gate leading to the backyard. LPA also observed Licensee's mother, Licensee's mother-in-law, one adult assistant, and three day care children (1 infant & 2 preschool) in the home during today's inspection. Days and hours of operation are Monday - Friday from 7:30 AM to 6:00 PM. The adults that reside in the home are the Licensee, spouse, and Licensee's mother. The Licensee has three children of her own, ages 15 and 12 years, that also reside in the home. The Licensee, Licensee's spouse, and Licensee's mother have valid CPR & First Aid certifications (expiration: February 2020). The Licensee's adult assistant has valid CPR and First Aid certifications (expiration: April 2020). LPA reviewed the Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last Fire/Disaster drill was completed on May 28, 2019. LPA observed that the Licensee and adult assistant has completed the required Mandated Reporter Training for Child Care Workers. LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters inside the home. The family room, fourth bathroom, and adjoining bathroom (located on the back end of the home) are the main areas of the home used for the day care. Off limit areas inside the home: three bedrooms, two bathrooms, kitchen/dining room areas, and attached garage. There are no stairs inside the home. Off limit areas outside the home: front yard, left side area of the backyard, and three locked sheds. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 07/11/2019):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2019

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ROSALES, MARY JANE	FACILITY NUMBER: 434411371
	VISIT DATE: 07/11/2019

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 07/11/2019):

LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water. The Licensee states that she does not have any weapons or pets in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Licensee states that she does not administer any medications to the day care children.

A review of staff records on July 9, 2019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded the Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than fourteen children in the home at any time without at least two qualified adults present. The Licensee states that she does not transport day care children.

LPA conducted an exit interview with the Licensee prior to the conclusion of today's inspection and the Licensee agreed to submit copies of her current immunization records and proof of completion of the Mandated Reporter training by Friday July 19, 2019.

No deficiencies issued during today's inspection.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2019

LIC809 (FAS) - (06/04)

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