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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412079
Report Date: 05/23/2019
Date Signed: 05/23/2019 03:38:33 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:DAVIS, APRILFACILITY NUMBER:
434412079
ADMINISTRATOR:DAVIS, APRILFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 903-9652
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:14CENSUS: 7DATE:
05/23/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:April DavisTIME COMPLETED:
03:45 PM
NARRATIVE
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On 05/23/2019 at 11:55 AM Licensing Program Analyst (LPA) Peter Tinkelenberg and Licensing Program Manager (LPM) Mary Segura conducted an unannounced annual random inspection. Licensee April Davis greeted us at her door. After disclosing the purpose of our visit, the Licensee granted us entry. Four day care children were observed in the home (1 infant and 6 children under years-old). An assistant was present. Licensee states that she's the only adult living in the home.. The Licensee stated that her hours of operation are Monday through Friday, from 5 AM to 10:30 PM. The facility License, Notification of Parents’ Rights, and Personal Rights were posted near the front entrance to the home.

At 12:05 PM LPA and LPN toured the indoor and outdoor areas of the home to ensure compliance with the standards established in CCR, Title 22. The Licensee has a working telephone in the home. The home has age-appropriate toys, play equipment, and materials for the day care children. The stairs to the second floor are barricaded. There is no fireplace but the home is heated and air conditioned for comfort. The home has a 2A10BC fire extinguisher that was last serviced on 08/15/2018. The home has a combination fire and carbon monoxide detector that is operating. The Licensee states she has no firearms or other dangerous weapons. The kitchen is free of sharp objects. However, a bottle of Windex was stored under the sink which was accessible to children in her care. Other accessible areas were also observed to store dangerous items. The closet in the play room contained hand lotions and other toiletries. A big bottle of ibuprofen was sitting on top of a bag in this closet. The closet has a key lock but at the time of the inspection the closet was open and unlocked. The attached garage is situated off the playroom. The door has a lock as well but is easily unlocked by the twist of a couple of fingers. As the garage was accessible, it was observed that bottles of laundry detergent were sitting on the ground near the washing machine.

The back yard was fenced. Debris of broken wood and used bricks were stored along the fence and behind and in the shed. The shed was not locked as the handle that would hold the lock was broken. Inside the shed was an empty bottle and and a bottle of coal starter fluid that was partially full.The back yard was also the home of a large puppy.

CONTINUATION OF THIS DOCUMENT ON PAGE 2 (DATED 05/23/2019)
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2019
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: DAVIS, APRIL
FACILITY NUMBER: 434412079
VISIT DATE: 05/23/2019
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 05/23/2019):

LPA discussed the requirements of AB 633 with the Licensee and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and the Licensee understands the requirements. LPA also discussed “violations requiring an immediate $500 civil penalty” with the Licensee. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

The following Type A and Type B Deficiencies were cited in accordance with California Code of Regulations, Title 22. Exit interview with licensee conducted, reviewed deficiencies, plans of correction. Appeal rights provided.

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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2019
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: DAVIS, APRIL
FACILITY NUMBER: 434412079
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2019
Section Cited
CCR
102417(g)(4)
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102417(g)(4) 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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By 5 PM May 24, 2019 the Licensee will make the identified cleaners, chemicals, and medicines inaccessible. The Licensee will provide photos as proof to the LPA via fax, text, or email.
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Based on observation, the Licensee failed to keep cleaners, medicines, and chemicals inaccessible, including but not limited to: windex was found under the kitchn sink, acetamenophen in the unlocked closet adjacent ot the play room and laundry detergent on the floor of garage. this which poses an immediate risk to the safety of the 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: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2019
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: DAVIS, APRIL
FACILITY NUMBER: 434412079
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2019
Section Cited
CCR
102370.1(b)(2)
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102370.1(b)(2) Criminal Record Exemptions. In addition to the requirements of Section 102370.1(a), the licensee must:Provide a copy of the Addendum to Notification of Parent's Rights (Regarding Removal/Exclusion) (LIC 995B Rev. 05/03) to one parent or authorized representative of every child currently in care within one day of receipt of the addendum from the Department.
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By 5 PM June 10, 2019 the Licensee will have the parents of the children in care sign the LIC 995B. The LIcensee will provide copies of the signed documents via fax, text, or email.

Today, the Licensee will be assessed a civil penalty of $100 per parent per day for a total civil penalty of $100.
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This requirement was not met as evidenced by:

The Licensee has failed to provide signed LIC 995B documents for child #4 in care today. Which poses a potential risk to the health and safety of the 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: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2019
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: DAVIS, APRIL
FACILITY NUMBER: 434412079
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2019
Section Cited
HSC
1596.8662
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HSC - 1596.8662 Training for Mandated Reporter who is licensed day care provider. ... a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training …

This requirement was not met as evidenced by:
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By 5 PM, July 8, 2019 the Licensee and assistant shall provide the LPA copies of the Mandated Reporter Training Certificates. The copies may be faxed or mailed to the LPA. Go to MandatedReporterca.com to complete training.
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Based on observation and interview, the Licensee and Assistant failed to meet the above requirement by not completing the training by January 1, 2018, which poses a potential risk to the safety of the children in care.
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Type B
06/23/2019
Section Cited
HSC
1597.622(a)(1)
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1597.622(a)(1) Employees or volunteers at family day care home; immunization requirements. … 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.
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By 5 PM, June 23, 2019 The Licensee will provide documentation of being immunized against the measles. The Licensee can provide a copy of the documentation via text, fax, or email.
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Based on inspection of staff records, Licensee has failed to provide immunization records for measles, which is a potential risk to the health and safety of the 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: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2019
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: DAVIS, APRIL
FACILITY NUMBER: 434412079
VISIT DATE: 05/23/2019
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 05/23/2019):

LPA and LPM reviewed the Child Care Facility Rosterand Fire/Disasterdrill log at 12:35 PM. The roster listed all the children in care. All the required documentation was observed. The last fire/disaster drill was completed more than six months ago (11/07/2018). LPA reviewed 4 children's files and observed that the file of each child contained complete immunization records and signed parent's rights forms. LPA Tinkelenberg inspected the files of the Licensee and the Assistant. The Licensee was missing the measles (MMR) vaccination. The Licensee chose not to be vaccinated against the flu. She did not take the Mandated Reporter Training for Child Care Workersbut does have a signed the Statement Acknowledging Requirement to Report ChildAbuse (LIC 9108). Licensees’ CPR and First Aid are current and expire on 12/2019. The Licensee's adult assistant's CPR & First Aid certifications are current and expire on 12/2019. The Assistant has the required immunization: pertussis (Tdap) and measles (MMR). The assistant was not vaccinated against the flu. Licensee and assistant have not completed the Mandated Reporter Training for Child Care Workersnor signed the Statement Acknowledging Requirement to Report ChildAbuse (LIC 9108).

A review of records confirmed for the moment that the Licensee and other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

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 14 children in the home at any time without a fully qualified adult present. The Licensee states that she will transport children occasionally and understands that she may do so according to the regulations for safe transport of children.

Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at 800-514-0301 (voice) / 800-514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htmhttp://www.ada.gov/childqanda.htm Licensee states that there are no children in her care who require IMS services.

CONTINUATION OF THIS DOCUMENT ON PAGE 3 (DATED 05/22/2019)
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2019
LIC809 (FAS) - (06/04)
Page: 6 of 6