434413368-9-26-2019-07-CC-MSMS-BGDR4T-20190926124203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413368
Report Date: 09/26/2019
Date Signed: 09/26/2019 12:42:08 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:	CACERES AGELVIZ, ZHAYDA		FACILITY NUMBER:	434413368
ADMINISTRATOR:	CACERES AGELVIZ, ZHAYDA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 701-7913
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95131
CAPACITY:	14	CENSUS: 9	DATE:	09/26/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Zhayda Caceres Agelviz		TIME COMPLETED:	12:45 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 Analysts (LPAs) Mel Matos, Susy Cervantes, and Araceli Almaraz met with Zhayda Caceres Agelviz, Licensee, for an unannounced annual/random inspection. LPAs also observed Licensee's sister, Milly Rodriguez (adult assistant), and nine day care children (3 infants & 6 preschool), and Licensee's 18 year old niece (DOB: 09/21/2001), in the home during today's inspection. Days and hours of operation are Monday - Friday from 7:30 AM to 5:30 PM. The adults that reside in the home are the Licensee, Licensee's spouse, Licensee's sister-in-law, Licensee's brother, and Licensee's two adult nieces. Licensee's certifications for CPR and First Aid are current and expire on June 1, 2021. Licensee's adult assistant (Milly Rodriguez) CPR and First Aid certifications are current and expire in August 25, 2020. LPAs reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on August 23, 2019. The Licensee has day care insurance and LPAs observed a valid certificate of insurance from Hays Companies. LPAs reviewed nine children's files and observed current and updated immunization records and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. LPAs observed that the Licensee and two adult assistants (Milly Rodriguez & Patricia Caceres Rodriguez) has record of the required immunization records. The Licensee and two adult assistants also has record of completion of the Mandated Reporter training for Child Care Workers (completed 03/21/2018). LPAs toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPAs observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPAs did not observe any wall heaters inside the home. Off limit areas in the home: master bedroom, master bathroom, one bedroom, furnace closet, locked bathroom vanity cabinet door, barricaded fireplace (located in the living room), and attached garage. There are no stairs inside the home. Off limit areas outside the home: front yard and right side area of the backyard. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 09/26/2019):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2019

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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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: CACERES AGELVIZ, ZHAYDA	FACILITY NUMBER: 434413368
	VISIT DATE: 09/26/2019

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 09/26/2019):

LPAs observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water. The Licensee states that she does not have any weapons or pets in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. The Licensee states that she does not administer any medications at this time.

A review of staff records on September 25, 2019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPAs also reminded the Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, 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.

LPAs reminded the Licensee that her adult niece (DOB: 09/21/2001) has 30 days from 09/21/2019 to get her fingerprint clearances. The Licensee states that she understands LPAs explanation.

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 with a qualified assistant present. The Licensee states that she does not transport children. The Licensee states that she does not administer any medications at this time.

No deficiencies issued during today's inspection. The Licensee agreed to submit copies of CPR/First Aid certifications, vaccination records and proof of completion of the Mandated Reporter Training for Child Care Workers to LPA Matos by Friday October 4, 2019.

LPAs conducted an exit interview with the Licensee prior to the conclusion of today's inspection and advised her of the pending Department regulation update re: safe sleep for infant children. LPAs referred the Licensee to the Department website: www.ccld.ca.gov for additional information.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2019

LIC809 (FAS) - (06/04)

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