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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413543
Report Date: 08/31/2021
Date Signed: 08/31/2021 01:39:10 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:PACHECO, SABRINA & NEUSAFACILITY NUMBER:
434413543
ADMINISTRATOR:SABRINA & NEUSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 469-2302
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:14CENSUS: 9DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Sabrina PachecoTIME COMPLETED:
01:50 PM
NARRATIVE
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#2 Licensing Program Analyst (LPA), Marilou Monico, made an unannounced Required - 1 Year inspection. None of two the adult helpers who were present in the home supervising nine preschool age children has current Pediatric CPR/First Aid certifications. Licensee and another adult helper (both have current CPR/First Aid certifications) arrived around 11:35 AM. LPA met with Licensee, Sabrina Pacheco, and explained the purpose of today's visit. Licensee and her husband are the adults residing in the home. The home has three bedrooms and two bathrooms. The daycare is open Monday to Friday from 8:00 AM to 5:30 PM.

LPA toured the home inside and out with the Licensee. LPA observed sufficient toys and play equipment for the day care children. Bathroom used by children was observed to be clean and in good condition.

Off limit areas in the home: two bedrooms (Bedrooms 1 & 3). Off limit areas outside the home: right side yard and detached garage. There were no bodies of water observed. Per Licensee, there are no weapons in the home. LPA observed a fully charged 2A10BC fire extinguisher, functioning carbon monoxide and smoke detectors, barricaded wall heaters, and fenced backyard. Cleaning compounds, detergents, medications, sharp objects, and other similar items were stored inaccessible to children. Fire drill was last conducted on June 12, 2021. Licensee maintains a current children's roster.

LPA discussed with Licensee Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years. Mandated Reported Training can be accessed at www.mandatedreporterca.com. Licensee's Mandated Reporter Training (AB1207) expires on July 8, 2023. Licensee's helpers have current Mandated Reporter Training certifications.

Continuation on next page:
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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: PACHECO, SABRINA & NEUSA
FACILITY NUMBER: 434413543
VISIT DATE: 08/31/2021
NARRATIVE
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A review of staff records during today's inspection 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.

LPA reviewed with Licensee the violations that would result in an immediate assessment of civil penalty in the amount of $500. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Adoptions of new laws, pay annual fees etc.
LPA reviewed with Licensee and provided her a copy of Safe Sleep Regulations (PIN 20-24-CCP).

Incidental Medical Services (IMS) policy was discussed. Licensee stated that she's not planning to provide IMS at this time.

The following updated forms were submitted today:

1) Application for a Family Child Care Home License (LIC 279); 2) Current Children In Your Home (LIC 279B)

Licensee to submit her husband's TB test and Criminal Record Statement (LIC 508) by September 15, 2021.

As a result of this inspection, deficiency was cited on the following page:



A NOTICE OF SITE VISIT WAS POSTED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: PACHECO, SABRINA & NEUSA
FACILITY NUMBER: 434413543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited

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Personnel Requirements - 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.
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This requirement is not met as evidenced by: LPA observed that none of the two adult helpers present with the daycare children has current Pediatric CPR/First Aid certifications.
This poses a potential risk to the health and safety to 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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021
LIC809 (FAS) - (06/04)
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