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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414513
Report Date: 02/09/2023
Date Signed: 02/09/2023 02:32:54 PM


Document Has Been Signed on 02/09/2023 02:32 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:ROBLES, LORENAFACILITY NUMBER:
434414513
ADMINISTRATOR:ROBLES, LORENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 660-6272
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:14CENSUS: 7DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Lorena RoblesTIME COMPLETED:
02:45 PM
NARRATIVE
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On 02/09/2023 at 10:41 AM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Lorena Robles, for an annual inspection and explained the reason for the visit to her. Present during today's visit were licensee and assistant Evelin, adult son, with 7 children: seven preschool children, one which is licensee four (4) year old son. Adults living in the home are licensee and her spouse, and adult son. Days and hours of operation are Monday through Friday 7:00 AM to 6:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 12/12/2022 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. 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.

LPA inspected inside and outside of the home. LPA observed a barricaded fireplace closed off inside the home, no wall heater, no stairs and no bodies of water. Licensee stated there are no weapons. Licensee stated they have no pets. LPA observed a fully charged 3A40BC fire extinguisher. A combo Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Off limits indoor: master bedroom, master bathroom, three bedrooms, one bathroom, and the garage. Off limits outdoor: left side yard which is used as a dog run. Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 12 children according to their license. Licensee stated they do not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size. Continues on report dated 02/09/2022

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ROBLES, LORENA
FACILITY NUMBER: 434414513
VISIT DATE: 02/09/2023
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Continuation of report dated 02/09/2023 pg. 2/2
LPA observed a fire and disaster drill log that was last conducted on 08/09/2022. LPA reviewed 5 children’s files and observed all required documentation was in compliance. The 15 minute check sleep log for infants under 24 months was discussed. LPA observed that the Licensee has Mandated Reporter training, training was completed on 12/10/2020, assistants Evelin completed 03/08/2021. Licensee has Pediatric CPR/1st Aid expiring 02/25/2023, assistants Evelin expiring 02/25/2023. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee and assistants.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

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.

One Type B deficiency was cited during today's visit.. Technical assistant provided for garage door and children file. Exit interview conducted and report was reviewed in Spanish with the licensee, Lorena Robles. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/09/2023 02:32 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: ROBLES, LORENA
FACILITY NUMBER: 434414513

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day 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 date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, Licensee Lorena Robles last completed Mandated Reporter Training on 12/10/2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
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Licensee will submitt a copy of proof on completion of Mandated Reporter Training to the San Jose Regional Office by close of business 02/24/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
LIC809 (FAS) - (06/04)
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