434412947-1-31-2023-07-CC-KMEO-CNLT54-20230131132454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434412947
Report Date: 01/31/2023
Date Signed: 01/31/2023 01:25:13 PM

Document Has Been Signed on 01/31/2023 01:25 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
SAN JOSE-DAY CARE, 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: 8	DATE:	01/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Stephanie Antoni		TIME COMPLETED:	02:00 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	On January 31st, 2023 at 11:30, Licensing Program Analyst (LPA) Kassandra Medrano conducted an annual required inspection which included a toured the home and yard, and a review of the required day-care forms with the licensee today. Present in the home is 8 children and 2 helpers. Licensee was not present in the home, staff contacted licensee and she returned to the home. Capacity and ratio requirements of children were observed in compliance today. This type of home is a single family, single story home. Adults living in the home are Licensee, and Husband, Fred. A review of records indicates that all adults working or living in the home who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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. The day-care operates 8am-1pm, Monday-Friday. Licensee has daycare insurance through: AP-intego. LPA observed the following: Day-care area is clean, orderly, and equipped with age-appropriate toys and equipment for the children. No baby walkers, bouncers, exercausers, etc. allowed to be used during day-care hours. Home has proper lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher. Licensee states there are no bodies of water on the property. There are no detergents, or cleaning products accessible to day-care children. Poisons are locked. Licensee states there are no guns or weapons of any kind in the home. The yard is fenced.Present in the home are 3 dogs, and one chicken, vaccinations current. Licensee’s CPR and First Aid expires 6/2023. Emergency drills are conducted at least once every six months and properly logged. Licensee provides one snack and parents are required to bring their children lunches. Isolation of sick children reviewed/discussed. Children’s roster was reviewed and is complete and up to date. Children and staff/helper files were reviewed, children's files were missing immunization's and staff files were missing updated mandated reporter training. Supervision and transportation of children was discussed. Capacity options were reviewed. Licensee understands that care cannot be provided for more than the capacity as stated on the license.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ANTONI, STEPHANIE	FACILITY NUMBER: 434412947
	VISIT DATE: 01/31/2023

NARRATIVE

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Requirements for reporting suspected child abuse was discussed, as well as reporting requirements for unusual incidences. Licensee has updated immunization's. Licensee was reminded that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. Licensee was informed about the Provider Information Notices (PINs) on CCLD website. Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com). LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage 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. This report and appeal rights were discussed with Licensee. This report must be available in the
facility for public review. 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/inspection-process.
Exit interview conducted and report was reviewed with the licensee, Stephanie

"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS. LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH APPLICANT/PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.

This TYPE A citation page shall be posted for 30 days along with the “Notice of Site Visit.” This page shall be provided to all parents of children currently enrolled, and any future children being enrolled for the next 12 months per AB 633 requirements..

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/31/2023 01:25 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ANTONI, STEPHANIE	FACILITY NUMBER: 434412947
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102370(d)

Criminal Record Clearance

(d) 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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 staff did not have fingerprint clearance, staff stated she has been at facility since september, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2023
	Plan of Correction
1 2 3 4	Staff was removed from facility and was informed she cannot return until she is given fingerprint clearance and associated to the facility

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 01/31/2023 01:25 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ANTONI, STEPHANIE	FACILITY NUMBER: 434412947
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)

Immunizations

(g) 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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review , the licensee did not comply with the section cited above in 9 out of 9 children files were missing documentation of immunizations which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/01/2023
	Plan of Correction
1 2 3 4	Licensee will send documentation of immunizations gathered from parents.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC809 (FAS) - (06/04)

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