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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413421
Report Date: 08/02/2019
Date Signed: 08/02/2019 09:54:48 AM

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:MORA, YOLANDAFACILITY NUMBER:
434413421
ADMINISTRATOR:MORA, YOLANDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 705-3870
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:14CENSUS: 0DATE:
08/02/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Mora, YolandaTIME COMPLETED:
09:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Almaraz, Araceli conducted an annual random inspection. LPA met with Licensee, Mora, Yolanda and explained the nature of today's inspection. Present during the inspection was the licensee and assistant/daughter Mora, Katelyn and one minor son. There were no children present. The hours of operation of the day-care are 7 AM to 6 PM, Monday through Friday. There are three adults residing in the home; Licensee, licensees spouse Mora, Hector and daughter Mora, Katelyn and two minor children. Licensee and assistant have CPR and First Aid, which has an expiration date of 07/21. LPA reviewed four 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. LPA observed that the Licensee and assistant have record of MMR & Tdap vaccinations as well as the opt out form for the flu vaccine. LPA observed a working smoke/carbon monoxide detector, 2A10BC fire extinguisher and no bodies of water were observed. LPA did not observe any heaters in the home. LPA observed no fireplace. LPA inspected the indoor and outdoor areas of the home today. Off limit areas in the home are as follows; Garage, and one bathroom.. Off limit areas outside the home are as follows: Right Side, which is fenced. The front yard is safety compliant and backyard is fully fenced. Medication, cleaning products and similar items are stored inaccessible to children. Poisons shall be locked. LPA observed a current roster, a current fire disaster/earthquake drills last log 96/14/2019. Licensee states that there are no weapons in the home. Licensee has no pets. Licensee has no day care insurance. Licensee has not completed Mandated Reporter Training, licensee understands training is to be completed every two years.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2019
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 4
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: MORA, YOLANDA
FACILITY NUMBER: 434413421
VISIT DATE: 08/02/2019
NARRATIVE
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Supervision of the children was discussed; the Licensee understands a cleared adult must be present in the home during day care hours. Licensees understand that the children must be supervised at all times. The Licensee understands the capacity options and ratio requirements. Licensee understands not to leave children in the car unattended. The Licensee states that there is no transporting of children currently.

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

A review of staff records on 07/30/2019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded 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.
Website for provider resources:http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2019
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MORA, YOLANDA
FACILITY NUMBER: 434413421
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2019
Section Cited
HSC
1596.8662(B)(1)
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Health and Safety Code: On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the
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Licensee will submit to LPA proof of completion of Mandated Reporter Training for licensee and assistant on or before 09/20/2019 via fax, mail or email.
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date on which he or she completed the initial mandated reporter training. This requirement was not met as evidenced by LPA oberved licensee failed to show proof of completion upon inspection. This poses a potential risk to the health and safety of the children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: MORA, YOLANDA
FACILITY NUMBER: 434413421
VISIT DATE: 08/02/2019
NARRATIVE
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LPA conducted an exit interview with the Licensee and advised the licensee of the pending Department regulation update re: safe sleep for infant children. LPA referred the Licensee to the Department website: www.ccld.ca.gov for additional information. LPA discussed the requirements of AB633 to Licensee.

The following Type B deficiency noted on the attached page (809-D): Appeal rights provided to the Licensee prior to the conclusion of today's inspection.



NOTICE OF SITE VISIT ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4