434414060-4-24-2023-07-CC-KMEO-CR7UXK-20230424155827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414060
Report Date: 04/24/2023
Date Signed: 04/24/2023 03:58:35 PM

Document Has Been Signed on 04/24/2023 03:58 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	JORDAN, ELIZABETH		FACILITY NUMBER:	434414060
ADMINISTRATOR:	JORDAN, ELIZABETH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 281-7855
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	14	CENSUS: 2	DATE:	04/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Elizabeth Jordan		TIME COMPLETED:	04:15 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) Kassandra Medrano conducted an annual required inspection which included a toured the home and yard, and a review of the required day-care forms with the licensee today. Present in the home is Licensee, 2 children. Capacity and ratio requirements of children were observed in compliance today. Adults living in the home are Licensee, Husband, adult daughter, Makayla, and Adult son, Anthony. A review of records indicated that adult son, was missing an exemption. 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 has been assessed since this regulation is violated. The day-care operates 7am-5:30pm, Monday-Friday. Licensee does not have daycare insurance and has parent affidavit in all children’s files. LPA observed the following: Day-care area is clean, orderly, and equipped with age-appropriate toys and equipment for the children. No baby walkers, bouncers, exercausers, etc. allowed to be used during day-care hours. Home has proper lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher. Licensee states there are no bodies of water on the property. There is in the day-care area. There are no detergents, or cleaning products accessible to day-care children. Licensee states there are no guns or weapons of any kind in the home. The yard is fenced. Licensee’s CPR and First Aid expires 6/2023. Emergency drills are conducted at least once every six months and properly logged. Licensee provides daily snacks and meals if needed, if children have a modified diet parents will provide the food needed. Isolation of sick children reviewed/discussed. Children’s roster was reviewed and is complete and up to date. Children and staff/helper files were reviewed and are complete. Supervision and transportation of children was discussed. Capacity options were reviewed. Licensee understands that care cannot be provided for more than the capacity as stated on the license. Requirements for reporting suspected child abuse was discussed, as well as reporting requirements for unusual incidences. All required postings are properly posted (License/Parent’s Rights poster/Emergency Disaster Plan and Earthquake Preparedness Checklist)

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JORDAN, ELIZABETH	FACILITY NUMBER: 434414060
	VISIT DATE: 04/24/2023

NARRATIVE

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Licensee has updated immunization's. Licensee was reminded that as of September 1, 2016, a person may
not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza,
pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and
1597.662. Licensee was informed about the Provider Information Notices (PINs) on CCLD website. Licensee
was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or
www.mandatedreporterca.com). LPA discussed the safe sleep regulations with 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 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. This report and appeal rights were discussed with Licensee. This report must be available in the
facility for public review. 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/inspection-process.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):

"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS. LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH APPLICANT/PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT. This TYPE A citation page shall be posted for 30 days along with the “Notice of Site Visit.” This page shall be provided to all parents of children currently enrolled, and any future children being enrolled for the next 12 months per AB 633 requirements.
Exit interview conducted and report was reviewed with the licensee, Elizabeth.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/24/2023 03:58 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JORDAN, ELIZABETH	FACILITY NUMBER: 434414060
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102370(d)(1)

Criminal Record Clearance

(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, licensee's son, Anthony Patino was missing criminal record exemption clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Licensee states that he lives back and forth between here and his fathers home. Prior to return to home son will get reprinted and complete supportive documents.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

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