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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414591
Report Date: 05/30/2019
Date Signed: 05/30/2019 01:34:10 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:VALDEZ, VANESSA & GOMEZ, LISETTEFACILITY NUMBER:
434414591
ADMINISTRATOR:VALDEZ & GOMEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 209-4648
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:14CENSUS: 7DATE:
05/30/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Vanessa ValdezTIME COMPLETED:
01:35 PM
NARRATIVE
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LPA Janet Tse met with licensee Vanessa Valdez for an annual/random inspection. LPA explained the nature of today's inspection to Licensee. Present were seven children including four infants with Licensee and her assistant (JL). Adults living in the home are Licensee, her husband, and her adult son. Days and hours of operation are Monday to Friday, 7:00am to 6:00pm. LPA observed co-licensee Lisette Gomez has moved out of the home, and is no longer residing at this address. Notifications of the removal of Lisette Gomez from the license were received by Licensing.

LPA toured the indoor and outdoor of the home. LPA observed a covered fireplace and no wall heaters. LPA observed the stairs are barricaded. The gate separates the playroom from the off limits areas of the home. Off limits indoor: the entire upstairs which consists of a master bedroom, a master bathroom, three bedrooms and a bathroom; garage, living room; kitchen; the foyer; dining room; laundry room; and the dining room. LPA observed two playpen in the off limits dining room. Licensee stated that they are used for infant napping only. LPA advised that the kitchen area cannot be used for napping once the children are old enough to climb out of the playpens. Licensee understands that the infants need to be supervised while napping in the playpens. Children have to go through the laundry room to access the children's bathroom. Licensee understands that children will be escorted to and will be supervised in the bathroom. Licensee stated there is no firearms/weapons in the home. Sharp objects, medicines, poisons and cleaning supplies were inaccessible to the children. Backyard is fenced. LPA observed a fenced swimming pool. Off limits outdoor: the swimming pool, fenced off deck area; and both side yards. LPA reminded licensee that she can only have 14 children according to her license.

LPA observed the fire extinguisher is empty and has expired. Smoke and carbon monoxide detector was operable. Home is clean and orderly with heating and ventilation for safety and comfort. LPA observed sufficient materials, toys, and play equipment for the day care children. Telephone is in working order. Children were supervised on the visit and LPA went over substitute options. LPA also discussed if Licensee

Facility Evaluation Report dated 05/30/2019 to be continued on next page:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2019
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 4
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: VALDEZ, VANESSA & GOMEZ, LISETTE
FACILITY NUMBER: 434414591
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2019
Section Cited
HSC
1597.622
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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Licensee shall forward a copy of the Assistant's immunization record for measles and pertussis to LPA by 06/27/2019 due date.
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This requirement was not met as evidenced by:
LPA observed there is no immunization record for measles, and pertussis in the Assistant's (JL) file. The Assistant was hired two months ago in March 2019.
This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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Type B
07/15/2019
Section Cited
HSC
1596.8662(b)
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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training...

This requirement was not met as evidenced by:
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Licensee shall forward a copy of the certification for the Mandated Reporter AB1207 Compliant Child Care Training to LPA by 07/15/2019 due date.
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LPA observed Licensee does not have certification for the Mandated Reporter AB1207 Compliant Child Care Training which is to be completed every two years.

This poses a potential risk to the Health, Safety, or Personal Rights of 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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: VALDEZ, VANESSA & GOMEZ, LISETTE
FACILITY NUMBER: 434414591
VISIT DATE: 05/30/2019
NARRATIVE
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Facility Evaluation Report dated 05/30/2019 to be continued from previous page:

transports children, they are never to be left in parked vehicles. Licensee also understands that she has to follow the car seat laws. LPA observed a dog in the home which is kept in the indoor off limits area of the home. Licensee stated the dog is vaccinated.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 05/29/2019 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.

LPA reviewed seven children's files. LPA observed that in each child’s record has a copy of the emergency information card that contains all of the information specified by regulation. LPA observed that Licensee has completed training on preventive health practices, and has current Pediatric CPR/1st Aid expiring 12/27/2019. LPA obtained a copy of the current roster of the children.

Licensee was given and explained the current forms for childcare. LPA discussed the immediate civil penalties for Zero Tolerance of $500; and an ongoing $100 per day per violation continues until the violation(s) is corrected. LPA also discussed the Healthy Beverage Act and AB633 requirements for type A violation. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) 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. SB 792 Immunization Requirements was discussed. LPA observed there is no TB clearance and immunization record for measles, and pertussis in the Assistant's (JL) file. The Assistant was hired two months ago in March 2019. Licensee does not have any record for measles. LPA observed Licensee does not have certification for the Mandated Reporter AB1207 Compliant Child Care Training which is to be completed every two years. The assistant's (JL) primary language is Spanish and is currently exempt for the training. Website to complete training: https://mandatedreporterca.com. Information regarding Infant Safe Sleep and Lead Poisoning were provided to Licensee.

An updated LIC 279 Application for a Family Child Care Home License was provided to LPA today to remove co-licensee Lisette Gomez from the license.

Deficiencies were cited. Notice of site visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: VALDEZ, VANESSA & GOMEZ, LISETTE
FACILITY NUMBER: 434414591
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2019
Section Cited
CCR
102417(g)(1)
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...The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal.

This requirement was not met as evidenced by:
LPA observed the fire extinguisher is empty and has expired
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Licensee shall purchase a fire extinguisher size 2A10BC or above and forward pictures of a copy of the purchase receipt and the fire extinguisher showing its size to LPA by 06/17/2019 due date.
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This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
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Type B
06/17/2019
Section Cited
CCR
102369(b)(9)
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Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement was not met as evidenced by:
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Licensee shall forward a copy of the Assistant's (JL) tuberculosis clearance to LPA by 06/17/2019 due date.
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LPA observed there is no TB clearance in the Assistant's (JL) file.

This poses a potential risk to the Health, Safety, or Personal Rights of 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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4