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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411726
Report Date: 02/19/2020
Date Signed: 02/19/2020 05:04:27 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:VILLARROEL, ELIZABETHFACILITY NUMBER:
434411726
ADMINISTRATOR:ALIZABETH V.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 265-2722
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:14CENSUS: 7DATE:
02/19/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Elizabeth VillarroelTIME COMPLETED:
05:10 PM
NARRATIVE
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LPA Janet Tse met with licensee Elizabeth for a Required - 1 Year inspection. LPA explained the nature of today’s visit to Licensee. LPA observed seven children including one infant with Licensee and her assistant Elitania Pedraza-Torres in the home during today’s visit. Present was also Licensee's 15 1/2-year-old child. Days and hours of operation are Monday to Friday, 7:00am to 5:30pm. The adults that reside in the home are Licensee, her husband, her adult son with a 15 1/2-year-old child. LPA observed one of Licensee's sons has become an adult. Information on the LIC 279 Application for a Family Child Care Home License needs to be updated.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 02/18/2020 was reviewed; and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately removes the individual and prevents them from returning to the home or having contact with children in care.

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 safe and sufficient materials, toys, and play equipment for the day care children. LPA observed a chlorox spray in the kitchen sink, cleaning agent underneath the kitchen sink, and medication on a chest next to the dining table accessible to children. LPA observed a fully charged 2A10BC fire extinguisher and a working combo smoke and carbon monoxide detector. Licensee stated there are no weapons/firearms in the home. LPA observed a dog inside the home. Licensee stated the dog is vaccinated. Off limit areas indoor: Rooms 1, 2, 3 and bathroom 1 (per facility sketch). LPA observed a fenced backyard and no bodies of water. LPA observed a locked storage shed and a bird cage with two birds in the backyard. Off limit areas outdoor: both side yards.

Facility Evaluation Report dated 02/19/2020 to be continued on next page: - Page 1 of 3 -
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 6
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: VILLARROEL, ELIZABETH
FACILITY NUMBER: 434411726
VISIT DATE: 02/19/2020
NARRATIVE
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Facility Evaluation Report dated 02/19/2020 to be continued from previous page:

LPA observed Licensee and her assistant have current CPR and First Aid certification expiring 04/14/2020 and 07/21/2021 respectively. A current roster of the children was provided to LPA today. LPA observed a fire and disaster drill log which is to be done at least once every six months. The last drill practiced was on 02/13/2020. LPA reviewed six children files. One of the seven children present (child #7) does not have a child's file. Children’s immunization records are either not documented, maintained or updated in form PM286 in child #1, 3, 4, 5's files. LPA observed no Notification of Parents’ Rights with parent's signature in child #1's files. There is no LIC 627 Consent for Emergency Medical Treatment with parent's signature in child #1's files. Licensee does not carry liability insurance. LPA observed no LIC282 Affidavits Regarding Liability Insurance with parent's signature in child #1,5, and 6's files.

Supervision of children was discussed with 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. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. LPA provided licensee with the ratio/capacity chart for her reference. Licensee stated that she does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.

A Family Child Care Home packet with updated Licensing forms was provided and explained to the Licensee prior to the conclusion. Department website: http://ccld.ca.gov provided to Licensee.

LPA also discussed "zero tolerance" related regulations with Licensee and advised her of the assessment of an immediate $500 civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements.

AB792 Immunization Requirements was discussed. LPA observed the required immunization records for Licensee and her assistant were in file.

Facility Evaluation Report dated 02/19/2020 to be continued on next page: - Page 2 of 3 -
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2020
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: VILLARROEL, ELIZABETH
FACILITY NUMBER: 434411726
VISIT DATE: 02/19/2020
NARRATIVE
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Facility Evaluation Report dated 02/19/2020 to be continued from previous page:

Effect of Lead Exposure handout dated 1/20/19 given during today’s inspection. Licensee understands that per Assembly Bill (AB 2370), written information regarding lead exposure needs to be given out to enrolling and re-enrolling parents or guardians. LPA reviewed infants safe sleep policies with Licensee and provided "A Child Care Provider's Guide to Safe Sleep.” More information can be found at https://cdss.ca.gov/inforesources/Child-Care-Licensing. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care. The Mandated Reporter AB1207 Compliant Child Care Training was also discussed. Website to complete training: https://mandatedreporterca.com. Licensee's primary language is Spanish and is currently exempt from the training.

Deficiencies were cited. An advisory note to update the LIC 279 Application for a Family Child Care Home License was issued. Notice of site visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2020
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: VILLARROEL, ELIZABETH
FACILITY NUMBER: 434411726
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2020
Section Cited

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Operation of a Family Child Care Home. 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.
This requirement was not met as evidenced by:
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LPA observed a chlorox spray in the kitchen sink, cleaning agent underneath the kitchen sink, and medication on a chest next to the dining table accessible to children.
This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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Type B
03/05/2020
Section Cited

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Immunizations. The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
This requirement was not met as evidenced by:
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Children’s immunization records are either not documented, maintained or updated in form PM286 in child #1, 3, 4, 5's files. Child #7 does not have a child's file.
This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2020
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: VILLARROEL, ELIZABETH
FACILITY NUMBER: 434411726
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2020
Section Cited

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Operation of a Family Child Care Home. An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee
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or registrant to consent to emergency medical care. / This requirement was not met as evidenced by: There is no LIC 627 Consent for Emergency Medical Treatment with parent's signature in child #1's files. Child #7 does not have a child's file. / This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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Type B
03/05/2020
Section Cited

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Admission Procedures and Parental and Authorized Representative's Rights. At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parents’ Rights, LIC 995A...
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This requirement was not met as evidenced by:
LPA observed no Notification of Parents’ Rights with parent's signature in child #1's files. Child #7 does not have a child's file.
This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2020
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: VILLARROEL, ELIZABETH
FACILITY NUMBER: 434411726
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2020
Section Cited

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Operation of a Family Child Care Home. A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.
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This requirement was not met as evidenced by:
LPA observed no LIC282 Affidavits Regarding Liability Insurance with parent's signature in child #1,5, and 6's files. Child #7 does not have a child's file.
This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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Type B
03/05/2020
Section Cited

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Child's Records. The licensee shall maintain, in each child's record, a copy of the emergency information card required in Section 102417(g)(7).
This requirement was not met as evidenced by:
Child #7 does not have a child's file.
This poses a potential risk to the Health, Safety, or Personal Rights of children in care.

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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2020
LIC809 (FAS) - (06/04)
Page: 6 of 6