434413156-6-14-2021-07-CC-SYIP-C3YTT8-20210614150020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413156
Report Date: 06/11/2021
Date Signed: 06/14/2021 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:	MADRIGAL, SANDRA		FACILITY NUMBER:	434413156
ADMINISTRATOR:	MADRIGAL, SANDRA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 767-2343
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	14	CENSUS: 7	DATE:	06/11/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Sandra Madrigal		TIME COMPLETED:	04:05 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 (LPAs) Samantha Yip and Elizabeth Larios conducted an unannounced Required 1 Year inspection. LPA met with Licensee Sandra Madrigal and explained the reason for the inspection. Upon arrival, Licensee, Licensee' 3 minor children, and 7 children were present. 2 of whom were infant age. Licensee's minor child was helping with the daycare children. Licensee's Assistant arrived shortly after. All adults present during today's inspection are fingerprint cleared. There is a board to post required posting, such as license, notification of parent's rights, and Emergency Disaster Plan. There is working phone in the home. The hours of operation are currently are Monday through Friday 7:30AM to 5:30PM. LPAs toured in the inside and outside of the home. The off-limit areas of the home are garage, the shed outside, the master bathroom, and the right side of the home. The home was observed to clean and orderly. Disinfectants, cleaning supplies and other items that could pose a risk to the children were observed to be inaccessible. There are fireplaces in the home, which are barricaded. All toys and equipment were observed to be age-appropriate. LPA observed that the crib has a tight fitted sheet. LPA also reviewed documentation for checking infant. There were no baby bouncers observed during today's inspection. There is fully charged fire extinguisher, functioning smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 06/03/2021. Licensee stated that there are no weapons, such as firearms, stored in the home. The backyard is used and is fenced. There is a swimming pool in the backyard, which has required fencing around it. LPAs observed that the fencing is starting to tear. Licensee stated that she will fix the fence and send proof to Licensing. There were no other bodies of water observed during today's inspection. LPA reminded Licensee to ensure that any gates to off-limit area are closed. -------------------CONTINUES 809 DATED 06/11/2021 PAGE 2-----------------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MADRIGAL, SANDRA	FACILITY NUMBER: 434413156
	VISIT DATE: 06/11/2021

NARRATIVE

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--------------------CONTINUATION OF 809 DATED 06/11/2021 PAGE 1-------------------------

Licensee stated that she currently does not transport children, but will start transporting children when the school year starts in the fall. Licensee understands that children cannot be left alone and unattended. Licensee stated that she currently is not providing Incidental Medical Services (IMS). A Plan for Providing IMS is on file.

LPA obtained a copy of facility roster. LPA also reviewed 4 children's files. The files reviewed include but not limited to emergency information card and Individual Sleeping Plan.

LPA reviewed Licensee's and her assistant's file. LPA and her assistant have a valid CPR/1st Aid, which expires on 05/15/2023. Licensee and her assistant completed the Mandated Reporter Training on 02/08/2020. Licensee understands that Mandated Reporter Training requires renewal every 2 years. Licensee and her assistance's have immunization records for measles and pertussis. LPA reminded Licensee to keep a copy of proof of influenza.

The adults living in the home are Licensee and her spouse. All adults have cleared criminal record, child abuse index clearance, and TB test. 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.

As a result of today's inspection, a Technical Violation was issued. An exit interview was conducted were this report and Technical Violation were discussed and provided to Licensee Sandra Madrigal. 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: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

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