434411371-3-5-2020-07-CC-MSMS-BMES4T-20200305123316

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411371
Report Date: 03/05/2020
Date Signed: 03/05/2020 12:33:26 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: 6	DATE:	03/05/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Mary Jane Rosales		TIME COMPLETED:	12:40 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 arrived at the home today at 10:45 AM for an unannounced Required - 1 year inspection. LPA was greeted by Mary Jane Rosales, Licensee, the nature of today's inspection was explained to her, and LPA was allowed access into the home. LPA also observed Licensee's mother (adult assistant) and six day care children (2 infants & 4 preschool) in the home during today's inspection. The Licensee was operating within the capacity specified on her license. The days and hours of operation are Monday to Friday from 7:30 AM to 6:00 PM. The adults that reside in the home are: Licensee, Licensee's spouse, and Licensee's mother. 11:15 AM: LPA reviewed a current Child Care Facility Roster during today's inspection. The Licensee conducts fire/disaster drills at least once every six months and documents the date and time of each drill. The Licensee's certifications for CPR and First Aid are not current and expired in February 2020. The Licensee documents immunization records and maintains and updates all records for children in care. The Licensee provides the child's parent or authorized representative with a copy of the Family Child Care Home Notification of Parents' Rights. 11:45 AM: LPA toured the indoor and outdoor areas of the home with the Licensee during today's inspection. The Licensee has a working telephone in the home. The home has safe toys, play equipment, and materials for the children. The home is clean and orderly with heating and ventilation for safety and comfort. 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. The entrance to the day care is through the right side gate leading to the backyard area. 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 03/05/2020):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020

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: 03/05/2020

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 03/05/2020):

The fire extinguisher and smoke & carbon monoxide detectors in the home meet State Fire Marshal standards. The home has a fenced backyard and no bodies of water. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. All poisons are inaccessible to children and stored in the locked storage shed & garage.

All individuals subject to a criminal record review have obtained a criminal record clearance or
exemption prior to working, residing, or volunteering in a licensed home. The Licensee understands that if she is temporarily absent from the home during day care hours, she must arrange for a substitute qualified adult to care for and supervise children in her absence.

The following "Type B" deficiency is noted on the attached page (LIC 809-D).

LPA conducted an exit interview with the Licensee and provided her with a copy of her appeal rights prior to the conclusion of 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: 03/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/06/2020 Section Cited	1 2 3 4 5 6 7	Personnel Requirements: 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.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Licensee's CPR & First Aid certifications expired in February 2020. This presents a potential risk to the health/safety of children in care.	8 9 10 11 12 13 14	The Licensee agreed to submit a copy of her renewed CPR & First Aid certifications to LPA by Monday April 6, 2020.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020

LIC809 (FAS) - (06/04)

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