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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412947
Report Date: 05/03/2019
Date Signed: 05/03/2019 03:00:26 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:ANTONI, STEPHANIEFACILITY NUMBER:
434412947
ADMINISTRATOR:ANTONI, STEPHANIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 394-5536
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:14CENSUS: 6DATE:
05/03/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Stephanie AntoniTIME COMPLETED:
03:00 PM
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Licensing Program Program Analysts Peter Tinkelenberg and Mel Matos met with Licensee Stephanie Antoni today to address the deficiencies cited on the unannounced annual/random inspection completed on April 23, 2019. At the time of arrival there were 6 children present. The deficiencies cited on April 23, 2019 were the following:

1.) Type A: per Section 102417(a):Operation of a Family Child Care Home - The home shall be kept clean and orderly.
2.) Type A: per Section 102417(g): Operation of a Family Child Care Home - (a) storage areas for poisons, firearms, and other dangerous items shall be locked; garage area was accessible to children (b) garden tools were accessible to children; (c) barbecue grill with gas tank were accessible to children.
3.) Type B: per HSC 1596.8662: Licensee did not have the Mandated Reporter Training certificate.
4.) Type B: per Section 102416(c): Personnel Requirements - The Licensee did not have current CPR & First Aid certifications.

(1) During today's inspection, LPAs observed that the backyard play area was clear of chicken droppings. Licensee stated that her routine with the chicken is to keep it in the chicken coop or on the front lawn, which is off limits to the children in care.
(2) The LPAs also observed that the gas tank underneath the grill is secured by a lock and the entire grill is covered, making the the grill inaccessible to the kids in care. The garden tools previously noted have been removed and not accessible by children in care. Garage area was locked and inaccessible during today's inspection.
3.) The Licensee provided copies of the Mandated Reporter Training certificates for herself and her assistant..
4.) The Licensee provided copies of the CPR and First Aid certifications. The CPR & First Aid certifications are valid from 5/2/2019 to 5/2/2021.

In concluding today's inspection, LPA's cleared the above deficiencies. No further deficiencies noted.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
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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