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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411726
Report Date: 12/14/2022
Date Signed: 12/14/2022 03:38:13 PM


Document Has Been Signed on 12/14/2022 03:38 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
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: DATE:
12/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Elizabeth VillarroelTIME COMPLETED:
03:45 PM
NARRATIVE
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On 12/14/2022 at 11:20 AM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Elizabeth Villarroel, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee with 6 children: 5 preschool and one infant, additional child arrived at 11:25 AM, Assistant (A2) and A3 were prensent, A4 arrived at later. Adults living in the home are licensee, her spouse and two adult children. Days and hours of operation are Monday through Friday 7:00 AM to 5:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 12/6/2022 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 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 inspected inside and outside of the home. LPA observed no fireplace, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated they have one dog and two parrots, licensee states dog is vaccinated. LPA observed a fully charged 2A10BC fire extinguisher. Carbon Monoxide detector and smoke detectors combo was operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored in off limit rooms. Off limit areas: three bedrooms, one bathroom, attached garage, barricaded right side back yard, locked storage shed.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to their license. Licensee stated they do not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.


Continues on report dated 12/14/2022 pg. 1/3
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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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Document Has Been Signed on 12/14/2022 03:38 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
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: 12/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation and record review, the licensee did not comply with the section cited above, A1- licensee 8/28/2020 completed, Assistant A2, A3, A4, have not started training, A5 completed 8/28/2020, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Licensee will submit proof of completion certificates to the San Jose Regional Office by close of business 01/31/2023.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above, proof of Immunization's missing for A1, A2, A3, A4, A5 missing proof of MMR, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2023
Plan of Correction
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Licensee will submit proof of vaccinations or immunity for Assistant's A1, A2, A3, A4 and A5 to the San Jose Regional Office by close of business 01/12/2023.
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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/14/2022 03:38 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
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: 12/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, Child (C1) missing Immunization's, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2022
Plan of Correction
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Deficiency was corrected during visit, licensee obtained proof of vaccinations for C1 during LPA annual visit.
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 observation, interview and record review, the licensee did not comply with the section cited above, Sleep logs missing for Child (C1) and C2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2022
Plan of Correction
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Licensee will submit copies of safe sleep logs to the San Jose Regional Office by close of business 12/29/2022.
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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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
VISIT DATE: 12/14/2022
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Continuation of report dated 03/23/2022 pg. 2/3

LPA took a picture of a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 12/08/2022. LPA reviewed 5 children’s files. Child 1(C1) file missing LIC 9227, Sleep log and Immunization record, C2 missing Infant Sleep Log, C3 and C5 LIC 700 Identification and Emergency card missing signature. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was provided and discussed and a 15 minute check sleep log for infants under 24 months was discussed. LPA observed that the Licensee has Mandated Reporter training, training was completed on 08/28/20 for licensee and A5, A2, A3, A4 have not started Mandated Repoerter Training. Licensee has Pediatric CPR/1st Aid expiring 11/11/23, Assitant (A2) expires 7/26/2024, A3 expires 10/23/23, A4 expires 7/3/2023, A5 expires 7/21/23. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is missing for A1, A2, A3, A4 and A5.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS 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. PIN 22-02-CCP was provided.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.




SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
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: VILLARROEL, ELIZABETH
FACILITY NUMBER: 434411726
VISIT DATE: 12/14/2022
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Type B deficiencies were cited during today's visit, documented on LIC809-D. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.


Exit interview conducted and report was reviewed in Spanish with the licensee, Elizabeth Villarroel. 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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC809 (FAS) - (06/04)
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