<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412563
Report Date: 09/05/2019
Date Signed: 09/05/2019 04:31:08 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:VERGARA, LAURAFACILITY NUMBER:
434412563
ADMINISTRATOR:LAURA VARGARAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 272-2472
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:14CENSUS: 3DATE:
09/05/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Laura VergaraTIME COMPLETED:
04:45 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
LPAs Janet Tse and Susy Cervantes met with Licensee Laura Vergara for an annual/random inspection and explained the nature of today’s visit to her. LPAs observed Licensee with one infant and two preschool children in the home during today’s visit. Licensee's sister Domitila Vergara who is also het assistant, Licensee's brother and brother-in-law, and Licensee's 11-year-old niece arrived at the child care home later. Days and hours of operation are Monday through Friday, 6:30 am to 9:30 pm. The adults that reside in the home are the licensee, her sister, brother-in-law, and her brother with children ages 15, 11, and 10.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 09/03/2019 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.

LPAs toured the inside and outside areas of the home during today’s inspection. LPAs observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPAs observed no stairs in the home as well as no fireplace/wall. LPAs observed safe and sufficient materials, toys, and play equipment for the children in care. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items were not stored inaccessible to children. LPAs observed shampoo and cosmetics in the children's bathroom; cleaning compounds and a caulking gun under the kitchen sink. LPAs observed a room where a twin size mattress was propped up against shelves and a child's mat, with a child laying, next to the mattress; a child was sleeping in a portable crib/play pen that is now too small for the child. LPAs observed a 3A40BC fire extinguisher that was last serviced on July 3, 2012 and has expired. LPAs observed a working smoke detector. LPAs observed a functioning carbon monoxide detector. Licensee stated there are no weapons/firearms in the home. Off limit areas indoor: two bedrooms.

Facility Evaluation Report dated 09/05/2019 continues on next page.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019
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 5
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: VERGARA, LAURA
FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2019
Section Cited

1
2
3
4
5
6
7
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 by:
8
9
10
11
12
13
14
Children 4, 6, and 7 did not have form PM286 on record. This poses a potential risk to the health, safety, or personal rights of the children in care.
8
9
10
11
12
13
14
Type B
09/26/2019
Section Cited

1
2
3
4
5
6
7
The home shall be free from. . . 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 Marshal.

This requirement was not met by:
8
9
10
11
12
13
14
Fire extinguisher was last serviced on July 3, 2012. This poses a potential risk to the health, safety, or personal rights to the children in care.
8
9
10
11
12
13
14
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: 09/05/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: VERGARA, LAURA
FACILITY NUMBER: 434412563
VISIT DATE: 09/05/2019
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
26
27
28
29
30
31
32
Facility Evaluation Report dated 09/05/2019 continues from previous page.

LPAs observed a fenced backyard and no bodies of water. LPAs observed garage and storage shed doors were open and unlocked. Laundry detergent, dish soap and other cleaning products were placed on washing machine that is located outside and is accessible to the children in care. LPAs observed a cat, a parrot, and two birds in cages outside. Cat litter container was left on rolling cart and accessible to children. LPA Tse advised Laura to clean bird feces daily before the children go into the backyard. Off limit areas outside the home: storage shed, detached garage, side yard behind garage.
LPAs observed Laura has current CPR and First Aid certification expiring 08/27/2021. LPAs observed a current roster of the children and a fire and disaster drill log which is to be done at least once every six months and was last conducted on 03/18/2019. LPAs reviewed 10 children files. Children’s immunization records are not documented, maintained, and updated in form PM286 in 3 children files. LPAs observed Notification of Parents’ Rights is in each child’s file.
Supervision of children was discussed with licensee and she understands that she must be present in the home during child 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 and only with an assistant. Licensee states that her sister/assistant does transport children via vehicle and she understands that car seat laws shall be followed and children cannot be left in parked vehicles unattended at any time.
A Family Child Care Home packet with a list of updated Licensing forms was provided and explained to the Licensee prior to the conclusion. Department website: http://ccld.ca.gov provided to Licensee. Information on Lead Poisoning and Safe Sleep was provided to Licensee. Licensee was advised to forward the information to parents. 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. LPAs 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. 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. LPAs discussed SB792 Immunization Requrements with Licensee. Licensee and assistant could not provide records or immunization for measles. Tdap, influenza, and also TB clearance.

Type B deficiencies were cited. 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: 09/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: VERGARA, LAURA
FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2019
Section Cited

1
2
3
4
5
6
7
Immunization Requirements:
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.
8
9
10
11
12
13
14
This requirement was not met by:
Licensee and assistant could not provide records or immunizations. This poses a potential risk to the health, safety, or personal rights of the children in care
8
9
10
11
12
13
14
Type B
09/26/2019
Section Cited

1
2
3
4
5
6
7
Application for license:
Evidence of a current tuberculosis clearance, as defined in regulations that the department shall adopt, for any adult in the home during the time that children are under care. . .

This requirement was not met by:
Documentation of TB testing could not be
8
9
10
11
12
13
14
provided during today's visit.
8
9
10
11
12
13
14
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: 09/05/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: VERGARA, LAURA
FACILITY NUMBER: 434412563
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2019
Section Cited

1
2
3
4
5
6
7
Operation of a 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 by:
8
9
10
11
12
13
14
Cleaning compunds, shampoo, cosmetics, cat litter, and caulking gun were not stored and inaccessible to the children in care. Shed and garage doors were also left unlocked and open. This presents a potential risk to the health, safety, or personal rights to the children in care
8
9
10
11
12
13
14
Type B
09/12/2019
Section Cited

1
2
3
4
5
6
7
Personal Rights:
To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement was not met by: a twin size mattress was propped next to sleeping child; portable crib too small for child sleeping in it.
8
9
10
11
12
13
14
This poses a potential risk to the health, safety, or personal rights to the children in care.
8
9
10
11
12
13
14
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: 09/05/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5