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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414303
Report Date: 10/01/2019
Date Signed: 10/01/2019 01:52:56 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:LECHUGA, ESTHERFACILITY NUMBER:
434414303
ADMINISTRATOR:LECHUGA, ESTHERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 706-8930
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:13CENSUS: 4DATE:
10/01/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Esther LechugaTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Samantha Yip and Nancy Rodriguez conducted an unannounced annual random inspection. LPAs met with Licensee Esther Lechuga and explained the reason for the inspection. Present during the inspection were Licensee, her mother, and 4 children, whom 2 were infant age.

License was observed to be posted. There is working phone in the home.

LPAs toured in the inside and outside of the home with Licensee. Licensee only uses the converted garage and the bathroom 1. The living room, kitchen, family room, dining room, all three bedrooms, bathroom 2, and the backyard are off-limit. There is no stairs in the home. There is a fireplace in the home, which is in the off-limit area of the home. Furniture and equipment, such as table, chairs, and, play yard, were observed to be in good condition. LPA reminded Licensee that any disinfectants, or cleaning supplies need to place where it is inaccessible to the children in care. LPAs observed bathroom for children's use. LPA observed there is sufficient amount of toys for the children in care. LPA reminded Licensee that baby walkers and bouncers are not permitted in the home. LPA observed a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. LPA reminded Licensee that fire/disaster drills need to be conducted every 6 months. Licensee stated there are no weapons, such as firearms, stored in the home. There were no bodies of water observed during today's inspection.

Licensee does not transport children at this time, but will go on walks with the children. LPA reminded Licensee about supervision of children when they go on walks.

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SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2019
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 5
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: LECHUGA, ESTHER
FACILITY NUMBER: 434414303
VISIT DATE: 10/01/2019
NARRATIVE
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------------continuation of 809 date 10/01/2019 page 2-------------------------------------

LPA also reviewed Safe Sleep information. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online Licensing Forms, Adoption of new Laws, etc.


In areas that were evaluated, a Type A and Type B deficiency has been cited. A civil penalty of $500 was assessed for caregiver background check. An exit interview was conducted, where this report, the citation, plan of correction, civil penalty, and appeal rights were discussed with Licensee.

LPA also discussed about AB 633 requirement to provided a copy of 809 report dated 10/01/2019 and obtain a signed copy LIC 9224 for each child in care within one business days. LPA also discussed with Licensee that a copy of this report and a signed copy of LIC 9224 is required for any newly enrolled children within the 12 month period. LPA provided a copy of LIC 9224 and fact sheet to Licensee.

A NOTICE OF SITE VISIT WAS ISSUE AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS; along with a copy of 809 report dated 10/01/2019.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: LECHUGA, ESTHER
FACILITY NUMBER: 434414303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2019
Section Cited

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CHILD'S RECORDS - The licensee shall maintain, in each child’s record...the signed and dated notice form LIC 995A: Parents Rights Notice, LIC 700: Identification of Parents...
This requirement is not met as evident by:
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Based on record review, Licensee does not have any documents/forms completed for the children present. This poses a potential risk to the health and safety to 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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: LECHUGA, ESTHER
FACILITY NUMBER: 434414303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2019
Section Cited

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Criminal Record Clearance. All individuals subject to a criminal record review...shall prior to working, residing, or volunteering in a licensed facility: Request a transfer of a criminal record clearance...
This requirement is not met as evident by:
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Based on record review, Licensee's brother is fingeprint cleared but did have fingerprints transfered to facility. This poses a immediate risk to the health and safety to the children in care.
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A civil penalty of $500 has been assessed.

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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) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: LECHUGA, ESTHER
FACILITY NUMBER: 434414303
VISIT DATE: 10/01/2019
NARRATIVE
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----------------------continuation of 809 dated 10/01/2019 page 1---------------------------------

A copy of the facility roster was obtained. Licensee does not have any paperwork for the children present during today's inspection. Licensee stated that C-1 and C-2 started on 09/30/2019 and C-3 stated on 10/01/2019. Licensee stated that she will obtained the paperwork for the children by today, 10/01/2019.

Licensee's immunization records for measles is on file. Licensee does have a valid CPR/1st Aid, which expires on 10/15/2019. Licensee completed an in-person Mandated Reporter Training and will obtain a copy of certificate. LPA discussed with Licensee that Mandated Reporter Training requires renewal every 2 years.

The adults over the age of 18 living in the home are Licensee, her mother, and her brother. Licensee's brother is fingerprinted, but is not associated to facility. Licensee and her mother are fingerprint cleared. Licensee will submit LIC 9182: Criminal Background Transfer Request and a valid ID for her brother to Licensing office by the end of today. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, 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.

Licensee stated that she currently does not have any children in care who requires IMS services. Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. For IMS information, see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Home Section 102417. 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.

-------------------continues on 809 dated 10/01/2019 page 3----------------------------------
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5