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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412635
Report Date: 10/24/2019
Date Signed: 10/24/2019 04:07:37 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:MORALES, SHAELONFACILITY NUMBER:
434412635
ADMINISTRATOR:MORALES, SHAELONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 242-7671
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:14CENSUS: 7DATE:
10/24/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Shaelon MoralesTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Tuoc Doan and Dung Mac met with Shaelon Morales, the Licensee for an unannounced annual inspection visit.

Days and hours of operation are: Monday-Saturday 7:00am-6:00pm. LPAs toured the home both inside and out. Off-limit areas inside the home are 2nd bedroom, kitchen, and garage. LPAs did not observe bodies of water. Licensee stated that there are no weapons in the home. Detergents, cleaning products, medications, hazardous and other toxic materials are inaccessible to children. LPAs observed a fully charged fire extinguisher. Smoke and Carbon Monoxide detectors were tested and proved to be functioning. Fireplace was barricaded. LPAs observed that there were materials, toys, and play equipment for the day care children.

Licensee stated that she currently does not transport day care children, but she may resume in the future. LPA reminded Licensee that children cannot be left in parked vehicles unattended at any time, the motor vehicles used to transport children shall be maintained in safe operating conditions, and all vehicle occupants must be secured in an appropriate restraint system.

The home has a small sized pet dog that is not kept inaccessible to children. Per Licensee, the dog is up to date with vaccinations.

LPAs reviewed the Child Care Facility Roster. The last fire/disaster drill was conducted on 07/09/19. Children's files were reviewed.

Licensee and Assistant Provider Vanessa Alvarez files were reviewed. Records reviewed include Tuberculosis clearance, Measles and Pertussis immunization, and required training. Licensee's Mandated Report training expires 11/08/20 and her Pediatric CPR & First Aid certification expires 06/29/21. LPAs reminded Licensee that the Mandated Reporter Training needs to be renewed every two years.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2019
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 4
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: MORALES, SHAELON
FACILITY NUMBER: 434412635
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2019
Section Cited

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IMMUNIZATIONS. The licensee shall document each child's immunizations [...] and maintain such documentation for as long as the child is enrolled. This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.
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This requirement is not met as evidenced by:
Per LPA's review of files, Licensee failed to maintain documentation of Child 1's immunization. This poses a potential risk to the health & safety of children.
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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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: MORALES, SHAELON
FACILITY NUMBER: 434412635
VISIT DATE: 10/24/2019
NARRATIVE
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A review of records on 10/24/19 shows that all staff and other adults who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Licensee is the only adult residing in the home. Licensee has Clearances for Tuberculosis, and Criminal Background and Child Abuse Index Checks. LPAs reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.

Facility's Incidental Medical Services (IMS) policy was discussed. Licensee stated that she currently does not have any children in care who requires IMS or administration of medication. 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) & link to Commonly Asked Questions and the ADA, available at:<http://www.ada.gov/childqanda.htm> .

Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Adoptions of new laws, pay annual fees etc.

Beginning January 1, 2019 Assembly Bill 2370 requires that all licensed homes to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPAs provided a copy of the “Lead Poisoning Facts Information Flyer” and Safe Sleep Information to Licensee.

In the areas that were evaluated, regulatory violations were observed at the time of the inspection. LPAs conducted an exit interview where this report, the citations, plan of corrections, and appeal rights were reviewed with Licensee.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: MORALES, SHAELON
FACILITY NUMBER: 434412635
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2019
Section Cited

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HEALTH & SAFETY CODE. 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 [...], pertussis, and measles. [...] The family day care home shall maintain documentation of the required immunizations.
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This requirement is not met as evidenced by:
Per LPAs' review of files, Licensee failed to maintain documented proof of Assistant Provider Vanessa Alvarez's immunization against Measles. This poses a potential risk to the health and safety of children in care.
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Type B
11/07/2019
Section Cited

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APPLICATION FOR LICENSE. Licensees and any adult in the home, shall provide evidence of a current tuberculosis clearance, performed and signed by a physician not more than one year prior to or seven days after first day of employment.
This requirement is not met as evidenced by:
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Per LPA's review of records, Licensee failed to provide evidence of a current Tuberculosis Clearance for Assistant Provider Vanessa Alvarez. This poses a potential risk to the health and safety of 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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4