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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415187
Report Date: 10/26/2021
Date Signed: 10/27/2021 08:12:43 AM


Document Has Been Signed on 10/27/2021 08:12 AM - 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:MACHUCA, ROMELIAFACILITY NUMBER:
434415187
ADMINISTRATOR:MACHUCA, ROMELIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 842-6907
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 8DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Romelia MachucaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 1 Year inspection. LPA met with Licensee's daughter, Rosina Flores. Upon arrival, present were Licensee's two adult daughter, who help with the daycare, and one day care child. Licensee Romelia Machuca arrived shortly after. LPA explained the reason for the inspection. 7 school-age children arrived around 2:30PM.

There is board to post required postings, such as license and Notification of Parents. There is working phone in the home. The hours of operation are Monday through Friday 6:30AM to 6:30PM and Saturdays 6:30AM to 12PM. Licensee owns the home and does not have liability insurance.

LPA toured in the inside and outside of the home with Licensee. The off-limit areas of the home are all four bedrooms, the restroom adjacent to the kitchen, laundry room, basement, and additional in the backyard. LPA observed that the door of all the off-limit rooms and restroom adjacent to the kitchen were open. LPA observed that there was empty bucket of plaster on the floor of the room adjacent to the kitchen. Licensee moved bucket of plaster to closet and closed the door. LPA also observed that there were make-up removal wipes and liquid make-up removal in the two bedrooms next to the off-limit bathroom, which state to keep out of reach of children. Licensee closed the door of the room. LPA reminded Licensee that the rooms off-limit need to be closed at all time. Licensee requested to make the two rooms adjacent by the front the door on-limits for the children. LPA inspected the rooms and observed that it was safe for children. Licensee stated that she will submit an updated LIC 999A: Facility Sketch to reflect the changes to the on-limit areas. There is toys

-----------------------CONTINUES ON 809 DATED 10/26/2021 PAGE 2---------------------------
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021
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: MACHUCA, ROMELIA
FACILITY NUMBER: 434415187
VISIT DATE: 10/26/2021
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----------------CONTINUATION OF 809 DATED 10/26/2021 PAGE 1------------------------------

for children and cots were observed to be in good condition. There is fully charged fire extinguisher, smoke detector, and carbon monoxide. The last fire drill was conducted on 09/20/2019. LPA reminded Licensee that fire drill need to be conducted every 6 months and documents. Licensee stated that she will conducted fire/disaster drill with children and send proof to Licensing.

The backyard is used and is fenced. LPA observed that there are toys and equipment for children. There were no bodies of water observed during today's inspection.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage 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 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.

Licensee and her daughter transport children and have a valid driver's license. Licensee went to pick up a school-age child and brought one of the daycare child with her. Licensee stated that she did not have a car seat for the child. LPA discussed and provided Licensee with car seat law. LPA discussed with Licensee about the requirement to have a car seat and booster seat for all children.

Licensee does not provide Incidental Medical Services (IMS). IMS policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, an Plan of Providing IMS must be submitted to Licensing. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514- 0301 (voice)/ (800) 514-0383 (TTY) and link to publications: Commonly Asked Questions about Child Care Center and the ADA, available at: http://www.ada.gov/childqanda.htm.

----------------------CONTINUES ON 809 DATED 10/26/2021 PAGE 3-------------------------
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: MACHUCA, ROMELIA
FACILITY NUMBER: 434415187
VISIT DATE: 10/26/2021
NARRATIVE
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----------------------CONTINUATION OF 809 DATED 10/26/2021 PAGE 2-----------------------

A copy of the facility roster was obtained during today's inspection. Seven (7) children's files were reviewed during today's inspection. The records reviewed include but not limited to emergency card and LIC 999A: Notification of Parents Rights. LPA reminded Licensee to ensure that forms all filled out and signed.

Licensee and her daughter's files were reviewed during today's inspection. Licensee and A-1 completed the Mandated Reporter training, but A-2 has not yet. Licensee stated that A-2 will complete the Mandated Reporter training and send proof to Licensing. Licensee and her daughters have immunization records for measles and pertussis. Licensee and her daughters have a valid CPR/1st Aid, which expires on 05/25/2023.

The adults living in the home are Licensee, her two adult daughters, her mother, and her brother. Licensee also has one minor child. Licensee, one of daughters, her mother, and her brother have cleared criminal record, child abuse index, and TB. A-2 turned 18 yeasr old on 09/2021 and completed Livescan on 08/25/2021. Based on facility roster dated 10/25/2021, A-2's fingerprints are not associated to facility number. A-2's fingerprints are still pending. LPA discussed with Licensee about checking with Licensing to ensure that all adults living in the home have cleared criminal record. LPA also discussed with Licensee about checking fingerprints through Guardians. Licensee stated that A-2 completed TB test on 10/22/2021 and send a copy to Licensing. 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.


--------------------CONTINUES ON 809 DATED 10/26/2021 PAGE 4---------------------------
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: MACHUCA, ROMELIA
FACILITY NUMBER: 434415187
VISIT DATE: 10/26/2021
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------------------CONTINUATION OF 809 DATED 10/26/2021 PAGE 3----------------------------

A updated LIC 279B, LIC 279, TB test for adults living in the home were obtained during today's inspection. Licensee stated that she will submit the following:
- Updated LIC 999A
- TB test for A-2

As a result of this inspection, two Type A citation and one Type B citation were cited. A civil penalty for $500 was issued for Criminal Record. Exit interview conducted and report, citation, plan of correction, and appeals rights were reviewed with Licensee Romelia Machuca.

LPA also discussed about AB 633 requirement to provided a copy of 09 report dated 10/26/2021 and obtain a signed copy LIC 9224 for each child in care within one business day. LPA also discussed with Licensee Romelia Machuca that a copy of this report and a signed copy of LIC 9224 is required for any newly enrolled children within the 12 month period. LPA will email a copy of LIC 9224 and fact sheet to Licensee Romelia Machuca.



A Notice of Site was given and must remain posted for 30 days; along with a copy of the 809 dated 10/26/2021 report.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/27/2021 08:12 AM - 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: MACHUCA, ROMELIA
FACILITY NUMBER: 434415187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The last fire drill was conducted on 09/20/20219, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2021
Plan of Correction
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By POC 11/02/2021, Licensee stated that she will conducted a fire/disaster drill and send proof to Licensing.
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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 10/27/2021 08:12 AM - 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: MACHUCA, ROMELIA
FACILITY NUMBER: 434415187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
102417(k)
All vehicle occupants must be secured in an appropriate restraint system.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited. Licensee went to pick up another child with another daycare child and did not have a car seat for the child, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
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Licensee stated that she will submit a written plan outlining how she will ensure that all children being transport have a car seat.
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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 10/27/2021 08:12 AM - 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: MACHUCA, ROMELIA
FACILITY NUMBER: 434415187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance:
(d)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. A-2 turned 18 years old on 09/2021 and completed Livescan on 08/25/2021, but is still pending. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
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A-2 completed Livescan on 08/25/2021, but is still pending. Licensee stated that she will check the status of A-2's fingerprint.
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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021
LIC809 (FAS) - (06/04)
Page: 7 of 7