<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413368
Report Date: 07/14/2022
Date Signed: 07/14/2022 11:37:17 AM


Document Has Been Signed on 07/14/2022 11:37 AM - It Cannot Be Edited

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, ZHAYDAFACILITY NUMBER:
434413368
ADMINISTRATOR:CACERES AGELVIZ, ZHAYDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 701-7913
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY:14CENSUS: 4DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Zhayda Caceres AgelvizTIME COMPLETED:
12:00 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 Caceres Agelviz, Licensee, for an unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed Licensee's sister-in-law (Milly Rodriguez) and four day care children (1 infant & 3 preschool) in the home during today's inspection. Licensee was operating within her capacity and ratio requirements. LPA observed the required postings, including the facility license, near the front entrance to the home. Days and hours of operation are Monday - Friday from 8:30 AM to 5:30 PM. The adults that reside in the home are the Licensee, Licensee's sister-in-law, Licensee's brother (Ramon Caceres Agelviz), and Licensee's two adult nieces (Patricia Caceres Rodriguez & Alexandra Caceres Agelviz).

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 June 15, 2022. Licensee states that she does have liability insurance through Assure Child Care Insurance Company and LPA observed a valid policy during today's inspection. Licensee has current CPR and First Aid certifications (expiration: July 2024). Licensee has the required vaccines (MMR, Tdap, & flu opt out) and is current with her Mandated Reporter Training for Child Care Workers. LPA reviewed four children's files and the files were complete with the required forms. LPA reviewed one staff file (Licensee) and the file was complete with the required forms.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. The home is clean, orderly, (including heating/air conditioning/ventilation), and safe for the day care children. There are safe & age appropriate toys, play equipment, and materials for the children in the home. There is no fireplace or wall heaters inside the home. Off limit areas in the home: master bedroom, master bathroom, two bedrooms, 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. The Licensee states that she does not have any pets or weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Licensee states that there are no poisons in the home. Licensee states that she does not administer any medications to the day care children.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 07/14/2022
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
26
27
28
29
30
31
32
Licensee states that she provides breakfast, snacks, and lunch to the day care children. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored. Licensee has a first aid kit in the home which includes a touch less thermometer. Licensee states that nobody smokes and she understands that smoking is prohibited in the home.

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

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. Licensee understands her capacity/ratio options and she understands that she cannot have more than 14 children present in the home without at least two qualified adults present. Licensee states that a child will be isolated in the living room area if necessary due to illness or communicable disease. Licensee states that does not transport any day care children. 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.

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 the 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 the 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.

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

Exit interview conducted and report was reviewed with the Licensee, Zhayda Caceres Agelviz. No deficiencies issued during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2