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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413431
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:57:41 PM


Document Has Been Signed on 08/10/2022 03:57 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:ZAMUDIO, MICHAELFACILITY NUMBER:
434413431
ADMINISTRATOR:ZAMUDIO, MICHAELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 227-0640
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:14CENSUS: 9DATE:
08/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Michael ZamudioTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Janette Cruz met with Michael Zamudio, Licensee, for an unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensee. LPA observed the Licensee, his spouse, Jennifer Zamudio and niece/adult assistant, Lynette Zamudio with nine children (one infant, five school age and three preschool) present in the home during today's inspection. LPA observed the required postings, including the facility license by the entry area of the home. Days and hours of operations are Monday - Friday from 6:30 AM to 5:30 PM. The Licensee, his spouse, niece(Lynette), and Licensee's son and daughter in-law, Michael Zamudio and Rebekah Marte are the adults residing in the home. No adult in the home has proof of current CPR and First Aid certification.

LPA reviewed the Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 06/06/2022. Licensee does not carry an active Child Care Liability Insurance. Licensee has the required vaccinations (MMR, Tdap, & flu opt-out) and is current with the Mandated Reporter Training for Child Care Workers (expiration: 09/29/2023). LPA reviewed nine children's files.

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.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
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: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431
VISIT DATE: 08/10/2022
NARRATIVE
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LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home, (408) 858-5459. LPA observed sufficient materials, toys, and play equipment for the day care children. Licensee states that a child
will be isolated in the living room of the home if necessary due to illness or communicable disease.

LPA observed the home that is clean, orderly, and safe for the day care children. LPA observed a blocked fireplace and no open face heaters in the home. Off limit areas inside the home : master bedroom, three bedrooms and garage. Off limit areas outside the of the home: left and right side of backyard with three locked storage sheds. LPA observed a fenced backyard.

LPA observed a fully charged 2A10BC fire extinguisher and working smoke/carbon monoxide detectors. LPA observed Licensee has pets (three small dogs). Licensee stated that pets are current with vaccinations. The Licensee states that they have weapons in the home. LPA observed two guns located in off limit rooms in the home. LPA observed Licensee's weapon (hunting rifle) is secured with trigger lock to meet regulatory requirements. Licensee stated that there were no ammunition in the home during today's inspection, There was an available gun safe that Licensee stated ammunition may be kept. Licensee understands that as per regulations, ammunition shall be stored separately from firearms. All other detergents, cleaning compounds, medications, and other similar items are inaccessible to children. All poisons are stored in the garage and locked shed. The Licensee states that she does not administer medication to the day care children at this time.

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
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431
VISIT DATE: 08/10/2022
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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.

Supervision of children was discussed with Licensee and he understands that he must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands his capacity options that he cannot have more than 14 children in the home at any time. Licensee states that he transports 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.



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.


Based on staff interview conducted, Licensee has not had an experience of caring for a child with food allergies needing modified diet or medical attention. LPA provided Licensee with website resources on managing food allergies at school and handling medical emergencies related to food allergies.

CDC Managing Food Allergies at School
https://www.cdc.gov/healthyschools/foodallergies/index.htm
American Academy of Pediatrics Healthy Children Medical Emergencies
https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/When-to-Call-Emergency-Medical-Services-EMS.aspx

Exit interview conducted and report was reviewed with the Licensee, Michael Zamudio Deficiencies were issued during today's inspection. See 809-D.

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

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/10/2022 03:57 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee and adult assistants present during inspection did not have proof of current Pediatric First Aid and CPR training which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2022
Plan of Correction
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Licensee will submit to LPA proof of Pediatric First Aid training certificate by POC date.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record reviews, the licensee did not comply with the section cited above. Licensee did not have child's file for Child 5 and Child 9 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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Licensee will submit Child's file for Child 5 and 9 that include all required information on the emergency information card.

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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/10/2022 03:57 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee does not have file for Child 5 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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Licensee will submit to LPA the child's file for Child 5 that include child's current immunization as per regulatory requirements by POC due date.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee does not have file for Child 5 and Child 9 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2022
Plan of Correction
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Licensee will submit to LPA child's file for Child 5 and Child 9 which includes the copy of the LIC995 Notice of Child Care Home Notification of Parent's Rights by POC due date.

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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
LIC809 (FAS) - (06/04)
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