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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414612
Report Date: 11/16/2021
Date Signed: 11/17/2021 11:45:19 AM

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, JENNYFACILITY NUMBER:
434414612
ADMINISTRATOR:CHAVEZ, JENNYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 439-1747
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:14CENSUS: 3DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jenny ChavezTIME COMPLETED:
12:40 PM
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On 11/16/2021, Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee, Jenny Chavez for an annual inspection and explained the reason for the visit to them. Also present in the home were three day care children (2 infants and 1 preschoolers).
Adults living in the home are licensee and her adult son (Miguel Chavez). Licensee states she is planning to move to Sacramento next year. LPA explained the change of location process to Licensee.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 11/16/21 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 covered fire place, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons and no pets in the facility. LPA observed a 3A40BC fire extinguisher. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored in the garage. Backyard is fenced. Off limit areas are bedroom 1 and 3, kitchen, garage, left and right side yards. Licensee states she walks children to the restroom to pass by the kitchen. LPA observed that entry to the kitchen is barricaded.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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: 11/16/2021
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Supervision of children was discussed with Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time with a qualified assistant. Licensee states that does not transport any day care children. Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Licensee has current CPR & First aid expiring on 05/16/23. Licensee has immunization against pertussis and measles. Licensee states she recently had her influenza vaccine. LPA advised her to place proof in her file.

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

LPA requests that Jenny send proof of completion of Mandated Reporter training. Training is available at www.mandatedreporterca.com

No deficiency cited.

NOTICE OF SITE VISIT WAS ISSUED AND SHALL BE POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
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