434413368-7-23-2021-07-CC-MSMS-C57TCJ-20210723143650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413368
Report Date: 07/23/2021
Date Signed: 07/23/2021 02:37:00 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: 3	DATE:	07/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Zhayda Agelviz Caceres		TIME COMPLETED:	03:00 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	Licensing Program Analyst (LPA) Mel Matos met with Zhayda Agelviz Caceres, Licensee, for an unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed three preschool children in the home during today's inspection. The Licensee was operating within her capacity and ratio requirements during today's inspection. LPA observed the required postings, including the facility license, near the front entrance to the home. The home has a working telephone (408) 701-7913. Days and hours of operation are Monday - Friday from 8:30AM 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. The Licensee has no adult assistants at this time due to low enrollment. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 03/05/2021. The Licensee has the required vaccinations (MMR, Tdap, & flu). The Licensee has current Mandated Reporter Training for Child Care Workers on file (exp: 03/24/22). LPA reviewed three children's files and observed current and updated Identification and Emergency Information (LIC 700) and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. The Licensee states that a child will be isolated in the front area of the living room if needed to because of illness or communicable disease. Safe sleep updated: LPAs discussed the new “Safe Sleep” regulations with the Licensee including the Individual Infant Sleeping Plan (LIC 9227). REPORT CONTINUED ON FOLLOWING PAGE #2 - REPORT DATED 07/23/2021)

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

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: CACERES AGELVIZ, ZHAYDA	FACILITY NUMBER: 434413368
	VISIT DATE: 07/23/2021

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 07/23/2021):

LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.

LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. There is no fireplace or open face 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.

LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. Licensee states that she has no pets or weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Any poisons are locked in the attached garage and inaccessible to the day care children.

A review of staff records on July 23, 2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA 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.

REPORT CONTINUED ON FOLLOWING PAGE #3 - REPORT DATED 07/23/2021):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

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: 07/23/2021

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 07/23/2021):

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 without a fully qualified adult present and that she must comply with the capacity & ratio requirements of the small Family Child Care Home license whenever she is alone with the children. The Licensee states that does not transport any day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

The Licensee indicates that she might move to Lathrop, CA within the next few weeks and that her brother will be applying for a new license at her current residence. LPA advised the Licensee that she will need to close her current license by August 30, 2021 if she does not want to pay the annual license fee for the 2021/2022 year.

Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPAs conducted an exit interview with the Licensee and advised her that no deficiencies issued during today's inspection.

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: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC809 (FAS) - (06/04)

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