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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412183
Report Date: 10/11/2022
Date Signed: 10/11/2022 01:13:04 PM


Document Has Been Signed on 10/11/2022 01:13 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:MARTINEZ, ANNAFACILITY NUMBER:
434412183
ADMINISTRATOR:ANNA MARTINEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 796-7645
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:14CENSUS: 5DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Anna MartinezTIME COMPLETED:
01:00 PM
NARRATIVE
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On 10/11/2022 at 9:41 AM, Licensing Program Analysts (LPA) Teodoro Trujillo met with assistant Anna J. Martinez, for an annual inspection and explained the reason for the visit to her. Present during today's visit were assistant and five (5) children: 3 infants and 2 preschool children. Adults living in the home are licensee, husband Everardo, assistant Anna and adult son Everardo. Days and hours of operation are Monday through Friday 8:00 AM to 5:30 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 10/10/2022 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 a barricaded fireplace inside the home, no wall heater, barricaded stairs, and no bodies of water. Licensee stated there are no weapons. Licensee has no pets. LPA observed a fully charged 3A40BC fire extinguisher last serviced on 12/2018. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored on top kitchen cabinet. Off limit areas: all upstairs rooms. LPA went over substitute options and reminded licensee they could only have 14 children according to their license. Licensee stated she does not transport children, LPA reminded assistant 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 10/11/2022

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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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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: MARTINEZ, ANNA
FACILITY NUMBER: 434412183
VISIT DATE: 10/11/2022
NARRATIVE
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Continuation of report dated 10/11/2022 pg. 2/2
LPA observed a fire and disaster drill log that was last conducted on 06/3/2022. LPA reviewed 5 children’s files and observed all required documentation was in compliance. The 15 minute check sleep log for infants under 24 months was discussed, safe sleep log has not been started. LPA observed that the licensee's and assistant Mandated Reporter training has not been completed, licensee last completed 4/3/2018 and assistant Anna last completed 7/10/2018. Licensee and assistant has Pediatric CPR/1st Aid expiring 7/11/2023. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee and assistant.

This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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.htm. PIN 22-02-CCP was provided to assistant.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

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.

The following B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may 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 with the assistant Anna. 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: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/11/2022 01:13 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: MARTINEZ, ANNA
FACILITY NUMBER: 434412183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

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, assistant states fire extinguisher has not been serviced since 12/2018, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2022
Plan of Correction
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Licensee will submit proof of service or purchase of the Family Child Care Home fire extinguisher to the San Jose Regional Office by close of business 10/26/2022.
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 interview and record review, the licensee did not comply with the section cited above, assistant Anna J. Martinez and licensee have not renewed the mandated reporter training since 2018, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2022
Plan of Correction
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Licensee will submit proof of renewal for mandated reporter training for herself and assistant Anna J. Martinez to the San Jose Regional Office by close of business 11/30/2022.

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: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 10/11/2022 01:13 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: MARTINEZ, ANNA
FACILITY NUMBER: 434412183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, licensee has not started a safe sleep log for three (3) infants in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2022
Plan of Correction
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Licensee and assistant will start a safe sleep log and submit copy of safe sleep log for children in care to the San Jose Regional office by end of business on 10/12/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5