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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412563
Report Date: 09/28/2022
Date Signed: 09/28/2022 04:02:27 PM


Document Has Been Signed on 09/28/2022 04:02 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:VERGARA, LAURAFACILITY NUMBER:
434412563
ADMINISTRATOR:LAURA VARGARAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 272-2472
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:14CENSUS: 4DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Laura VergaraTIME COMPLETED:
04:15 PM
NARRATIVE
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On 09/28/2022 at 10:34 AM, Licensing Program Analysts (LPA) Teodoro Trujillo met with licensee, Laura Vergara, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee and assistant Domitila Vergara, assistants children ages 13 and 15, with 4 children: three preschool and one infant. Adults living in the home are licensee, her sister Domitila, brother in law Carlos, brother Raul Vergara and adult nephew Lawrence and 2 children. Days and hours of operation are Monday through Friday 6:00 AM to 6:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 09/19/2022 was reviewed and it indicates that not all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. Licensee nephew has not obtained criminal background clearance. 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 inside the home, no wall heater, no stairs and no bodies of water. Licensee stated there are no weapons. Licensee has one cat and birds with current vaccinations. LPA observed a fully charged 3A40BC fire extinguisher that was purchased on 9/17/2019. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons are inaccessible to the children and stored on top kitchen cabinet. Shampoo were accessible in infant room, assistant immediately removed shampoos and stored them in the top bathroom cabinet. Off limit areas: two bedrooms. Outside off limit area: two storage sheds and off limit Garage.

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 09/28/2022 pg. 1/3
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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 9


Document Has Been Signed on 09/28/2022 04:02 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: VERGARA, LAURA
FACILITY NUMBER: 434412563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022

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 and record review, the licensee did not comply with the section cited above, licensee last purchased/serviced fire extinguisher on 9/17/2019, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Licensee will submit proof of service or purchase of a new fire extinguisher by close of business 10/13/2022.
Type B
Section Cited
CCR
102417(g)(4)
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: (4) 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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, detergents were accessible to children in care in the infant room, kitchen and bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Licensee assistant Domitila immediately removed the detergents all accessible areas and stored them in a top bathroom cabinet.

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: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9


Document Has Been Signed on 09/28/2022 04:02 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: VERGARA, LAURA
FACILITY NUMBER: 434412563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

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. licensee stated child 7 (C7) did not have a safe sleep log, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Safe sleep log for C7 was started during LPA vist on 09/28/2022.
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: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 09/28/2022 04:02 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: VERGARA, LAURA
FACILITY NUMBER: 434412563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)


This requirement is not met as evidenced by:All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, licensee nephew Lawrence A. Sagui has not obtained a criminal record clearance or exemption or transfer been requested, which posses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Licensee will have nephew Lawrence A. Sagui complete a background check before being admitted back to home or request a criminal record transfer LIC 9182 to The San Jose Regional Office by end of business day 09/29/2022.
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: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 7 of 9


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: 09/28/2022
NARRATIVE
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Continuation of report dated 09/28/2022 pg. 2/3

LPA observed a fire and disaster drill log that was last conducted on 09/14/2020. LPA reviewed 7 children’s files, Child(C7) missing safe sleep log, C3 and C4 were missing LIC 627 Consent for Medical Treatment. The 15 minute check sleep log for infants under 24 months was discussed, licensee was provided a sleep log. LPA observed that the Licensee has Mandated Reporter training, training was completed with Child Care Providers United on 05/12/2022 and assistant Domitila on 1/21/2022. Licensee and assistant has Pediatric CPR/1st Aid expiring 08/27/2023. 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.

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.

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.

Continues on report dated 09/28/2022 pg. 2/3

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

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: 09/28/2022
NARRATIVE
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Continuation of report dated 09/28/2022 pg. 2/3

The following type A and 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.

LPA Teodoro Trujillo informed licensee Laura Vergara that this report dated 09/28/2022 document(s) one (1)) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Teodoro Trujillo informed the licensee Laura Vergara to provide a copy of this licensing report dated 09/28/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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.

Exit interview conducted and report was reviewed in Spanish with the licensee, Laura Vergara

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

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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