434412947-2-20-2020-07-CC-SYIP-BLZ2A8-20200220161307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434412947
Report Date: 02/20/2020
Date Signed: 02/20/2020 04:13:11 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, STEPHANIE		FACILITY NUMBER:	434412947
ADMINISTRATOR:	ANTONI, STEPHANIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 394-5536
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	14	CENSUS: 4	DATE:	02/20/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:53 PM
MET WITH:	Stephanie Antoni		TIME COMPLETED:	04:25 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	Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced annual random inspection. LPA met with Licensee Stephanie Antoni and explained the reason for the inspection. Present during today's inspection were Licensee, her Assistant, and 4 children. All adults present have cleared fingerprints. License was observed to be posted. There is working phone in home. The hours of operation are Monday through Friday 8AM to 500PM. Licensee does carry daycare insurance. LPA toured the inside and outside of the home with Licensee. The off-limit areas of the home are all three bedrooms, bathroom in the main house, kitchen, and the garage. There are no stairs or fireplace in the home. All disinfectant, cleaning supplies, and other items that are dangerous to children were stored inaccessible to children. Furniture and equipment, such as napping cots, chairs, and tables, were observed to be age appropriate. LPA observed that there is sufficient amount of toys for children in care. There were no baby walkers or bouncers observed during today's inspection. Bathroom for children's use was observed. LPA observed a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. LPA reminded Licensee that she needs to have a functioning smoke detector at all times. The last fire/disaster drill was conducted on 02/20/2020. LPA reminded Licensee that fire/disaster drills need to be conducted every 6 months and documented. Licensee stated that there are no weapons, such as firearms, stored in the home. The backyard is used and is fenced. There is a play structure, which is anchored to the ground. There were no bodies of water observed during today's inspection. LPA reminded to ensure that she is cleaning any chicken dropping. *-------------------------continues on 809 dated 02/20/2020 page 2--------------------------------*

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

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 2

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: ANTONI, STEPHANIE	FACILITY NUMBER: 434412947
	VISIT DATE: 02/20/2020

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

----------------------continuation of 809 dated 02/20/2020 page 1---------------------------------
Licensee stated that she does not currently transport children, but understand that children cannot be left alone and unattended in parked vehicles. Licensee also stated that she currently does not have any children who requires Incidental Medical Services (IMS).

4 children's files were reviewed during today's inspection. The records reviewed include but not limited to immunization records and parent's rights. LPA reminded Licensee to check that children enrolled have all the required forms filled out.

Licensee and her assistant's files were also reviewed. The records reviewed include but not limited to Mandated Reporter Training and immunization records for measles and pertussis. Licensee has her immunization record for measles and will obtain her immunization record for pertussis. Licensee stated that she will send a copy of immunization record for pertussis to Licensing office. Licensee and her assistant have completed the Mandated Reporter Training. LPA reminded Licensee that the Mandated Reporter Training requires renewal every 2 years. Licensee and her assistant both have a valid CPR/1st Aid. Licensee's CPR/1st Aid expires on 05/02/2021.

The adults living in the home are Licensee and her spouse. All adults have cleared criminal record clearance, child abuse index, and TB test results. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

LPA provided Licensee with Lead Exposure. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online Licensing Forms, Adoption of new Laws, etc.

In the areas evaluated during today's inspection, no deficiencies have been cited. An exit interview was conducted where this report was discussed and provided to Licensee Stephanie Antoni. A notice of site visit has been issued and must be posted for 30 consecutive days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2