434414591-2-20-2020-07-CC-SYIP-BLYUGL-20200220143430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414591
Report Date: 02/20/2020
Date Signed: 02/20/2020 02:34:41 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		FACILITY NUMBER:	434414591
ADMINISTRATOR:	VALDEZ, VANESSA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 209-4648
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	14	CENSUS: 12	DATE:	02/20/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:18 AM
MET WITH:	Vanessa Valdez		TIME COMPLETED:	02:40 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) Samantha Yip conducted an unannounced annual random inspection. LPA met with Licensee Vanessa Valdez and explained the reason for the inspection. Present during today's inspection were Licensee, 2 assistants, and 12 children, whom three (3) were infant age. All adults present have cleared fingerprints. License, Emergency Disaster Plan, and Notification of Parent's Rights were posted. There is working phone in the home. LPA toured in the inside and outside of the home. The off-limit areas of the home are the entire upstairs, living room, kitchen, dining room, garage, deck, pool, left and right side of the backyard. The stairs and fireplace are barricaded. Disinfectant, cleaning supplies, and other items that are dangerous to children were observed to be stored inaccessible to children. LPA reminded Licensee anything that states keep out of reach of children, such as diaper creams, should be stored inaccessible. Furniture and equipment, such as high chairs, play yard, napping cots, chairs, and tables, were observed to be in good condition. There were no baby walkers or bouncers observed during today's inspection. LPA observed that there is sufficient amount of toys for children in care. Restroom for children's use was observed to be clean. LPA observed a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 12/18/2019. Licensee stated that there are no weapons, such as firearms, stored on the premise. The backyard is fenced. There is sufficient amount of play equipment and toys for children. LPA reminded Licensee to check plastic play structure for any cracks. LPA also *--------------------------continues on 809 dated 02/20/2020 page 2------------------------------*

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

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: VALDEZ, VANESSA	FACILITY NUMBER: 434414591
	VISIT DATE: 02/20/2020

NARRATIVE

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-----------------------continuation of 809 dated 02/20/2020 page 1-------------------------------

discussed with Licensee about her plans for the fence. LPA observed that some of the panels are starting to get loose. There is pool in the backyard, which is fenced.

Licensee does not currently transport children at this time, but understands that children cannot be left alone and unattended in parked vehicles. Licensee also stated that she currently does not have any children in care who requires Incidental Medical Services (IMS).

10 children's files were reviewed during today's inspection. The records reviewed include but not limited to Consent for Emergency Medical Treatment, parent's rights and Affidavit for Liability Insurance. LPA reminded Licensee to check that all forms are filled out and signed by parents.

3 staff files were reviewed during today's inspection. The records reviewed include but not limited to the Mandated Reporter Training, immunization record for measles and pertussis, TB test results, LIC 508, and LIC 9108. Licensee's certificate for Mandated Reporter Training and immunization for measles and pertussis are on file. LPA reminded Licensee that Mandated Reporter Training requires renewal every 2 years. Both Assistants did not have TB test results on file. Licensee provided Licensee with a list of the required forms and documents for any Assistants. A-1 has completed the Mandated Reporter Training. Licensee stated that A-2 is waiting for the Spanish Mandated Reporter Training. Licensee stated that she will submit a copy of the required forms to Licensing office. Licensee and her Assistants all have a valid CPR/1st Aid. Licensee's CPR/1st Aid expires on 12/17/2021.

The adults living in the home are Licensee, her spouse, and her son. All adults have cleared criminal record clearance, child abuse index, and TB test results.

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SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

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	FACILITY NUMBER: 434414591
	VISIT DATE: 02/20/2020

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---------------------continuation of 809 dated 02/20/2020 page 2---------------------------------

LPA discussed and provided Licensee with Safe Sleep and Lead Exposure. 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 the areas evaluated during today's inspection, a Type B deficiency has been cited and a civil penalty of $250 for repeat violation has been issued. An exit interview was conducted where this report, citation, plan of correction, civil penalty, and appeal rights were discussed and provided to Licensee Vanessa Valdez. A Notice of Site Visit has been issued and must be posted for 30 consecutive days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

LIC809 (FAS) - (06/04)

Page: 3 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	FACILITY NUMBER: 434414591
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/20/2020 Section Cited	1 2 3 4 5 6 7	Application for Initial License. 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 is not met as evident by:
	8 9 10 11 12 13 14	Based on record reviews, Licensee did not have TB test results on file for Assistants. This poses a potential risk to the health and safety to the children in care.	8 9 10 11 12 13 14	A civil penalty of $250 was assessed.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

LIC809 (FAS) - (06/04)

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