434414612-12-11-2019-07-CC-JTSE-BJS3R9-20191211172822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414612
Report Date: 12/11/2019
Date Signed: 12/11/2019 05:28:36 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:	CHAVEZ, JENNY		FACILITY NUMBER:	434414612
ADMINISTRATOR:	CHAVEZ, JENNY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 899-2885
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95050
CAPACITY:	14	CENSUS: 2	DATE:	12/11/2019
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME BEGAN:	04:10 PM
MET WITH:	Jenny Chavez		TIME COMPLETED:	05:30 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	LPA Janet Tse met with licensee Jenny Chavez for an annual/required inspection. Present were two children including one infant with Licensee in the home. Adults living in the home are Licensee and her adult son. Days and hours of operation are Monday to Friday, 8:30am to 5:30pm. LPA toured the indoor and outdoor of the home. LPA observed a glass door covered fireplace and no wall heaters. LPA observed no stairs in the home. Off limits indoor: bedroom 3, bedroom 1, bathroom in bedroom 1, and the garage. There are no bodies of water. Licensee stated there is no firearms/weapons in the home. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Backyard is fenced. Off limits outdoor: both side yards. LPA reminded licensee that she can only have 14 children according to her license. Fire extinguisher is size 3A40BC and filled. The combo smoke and carbon monoxide detector is 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 number has been changed to 408-439-1747. Children were supervised on the visit and LPA went over substitute options. LPA also discussed if licensee transports children, they are never to be left in parked vehicles, and car seat laws shall be followed. A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 12/09/2019 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 three childrens' 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/1^st Aid expiring 04/06/2021. Facility Evaluation Report dated 12/11/2019 to be continued on next page: - Page 1 of 2 -

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2019

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: CHAVEZ, JENNY	FACILITY NUMBER: 434414612
	VISIT DATE: 12/11/2019

NARRATIVE

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Facility Evaluation Report dated 12/11/2019 to be continued from previous page:

Licensee was given a list of the current forms for child care. Website to download forms and to review regulations: http://www.ccld.ca.gov.

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. AB792 Immunization Requirements was discussed. LPA observed Licensee's immunization records for measles and pertussis were not in file. Licensee opts out of the influenza vaccine.

Effect of Lead Exposure handout dated 1/20/19 given during today’s inspection. Licensee understands that per Assembly Bill (AB 2370), written information regarding lead exposure needs to be given out to enrolling and re-enrolling parents or guardians. LPA reviewed infants safe sleep policies with Licensee and provided "A Child Care Provider's Guide to Safe Sleep.” More information can be found at https://cdss.ca.gov/inforesources/Child-Care-Licensing. 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.

The Mandated Reporter AB1207 Compliant Child Care Training was also discussed. Website to complete training: https://mandatedreporterca.com. Licensee's primary language is Spanish and is currently exempt from the training.

Website for provider resources: https://cdss.ca.gov/inforesources/Child-Care-Licensing. Periodic information releases accessible by signing up at: www.myccl.ca.gov.

Deficiency was cited. Notice of site visit was issued and must be posted for 30 days.

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SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: CHAVEZ, JENNY	FACILITY NUMBER: 434414612
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/11/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/16/2020 Section Cited	1 2 3 4 5 6 7	Immunization Requirements. 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.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: LPA observed Licensee's immunization records for measles ard pertussis were not in file. This poses a potential risk to the Health, Safety, or Personal Rights of children in care.	8 9 10 11 12 13 14
	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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3