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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413359
Report Date: 02/16/2024
Date Signed: 02/16/2024 01:57:26 PM


Document Has Been Signed on 02/16/2024 01:57 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:GABOIAN, AIDAFACILITY NUMBER:
434413359
ADMINISTRATOR:GABOIAN, AIDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 506-9794
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:14CENSUS: 11DATE:
02/16/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Gaboian, AidaTIME COMPLETED:
02:10 PM
NARRATIVE
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On 2/16/2024, at 11:00 AM, Licensing Program Analyst (LPA) Doni Fici arrived unannounced to conduct a Required 3-Year inspection and was greeted by Licensee, Gaboian, Aida, and explained the purpose of the visit.

Days and hours of operation are Monday to Friday from 8:00 AM to 5:00 PM. Licensee stated that the licensee is the only adult residing in the home. Upon entrance, LPA observed two (2) staff and eleven (11) children in care during inspection. Licensee's certifications for CPR and First Aid is current and will expire on 9/2025



LPA toured the indoor and outside areas of the home with licensee during today's inspection. LPA obtained a copy of the Child Care Facility Roster during today's inspection, and it is current. LPA reviewed five (5) child's file and observed that parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification and emergency information forms are in each file. LPA review two (2) staff files and observed all forms/documentation's. LPA observed that last fire drill was documented on 9/9/2023.

The Licensee has a working cell phone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. LPA observed there are stairs in the home leading to the second floor. Off limit areas in the home is the entire upstairs, and garage. Licensee uses the entire back yard as a playground for kids.

LPA observed a fully charged 2A10BC fire extinguisher which is serviced. LPA observed working smoke and carbon monoxide detectors. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children.

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SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: 408-598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GABOIAN, AIDA
FACILITY NUMBER: 434413359
VISIT DATE: 02/16/2024
NARRATIVE
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LPA observed Licensee has proof of immunization for pertussis, measles, and influenza in her file for herself according with the SB792.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time and a helper must be present. The Licensee states that she does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.

Department website: www.ccld.ca.gov provided to Licensee.

LPA discussed the requirements of AB 633 with the Licensee. LPA also discussed "zero tolerance" related regulations with the Licensee. Licensee has completed the required "mandated reporter" training on 6/8/2023. Licensee understands that all adults in contact with children are required to complete the training. LPA provided licensee with the website address for the training: www.mandatedreporterca.com. for additional information.

A review of staff records on 2/16/2024 indicates that all Facility staff or other individuals 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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.


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SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: 408-598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GABOIAN, AIDA
FACILITY NUMBER: 434413359
VISIT DATE: 02/16/2024
NARRATIVE
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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.

Incidental Medical services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. Licensee currently has no kids that need IMS assistance.

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/process.

The following type B deficiency was cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.



A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted with Licensee, and a copy of this report reviewed and provided.

SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: 408-598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/16/2024 01:57 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: GABOIAN, AIDA
FACILITY NUMBER: 434413359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102370(d)(2)
102370(d)(2)- Criminal Record Clearence:
(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:

(2) Request a transfer of a criminal record clearance as specified in Section 102370(j).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring S2 is cleared to be working in the home during operation hours which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee agreed to get S2 associated to the home by completing and submitting a Criminal transfer request to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: 408-598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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