434415230-9-23-2021-07-CC-MSMS-C75N4N-20210923100813

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415230
Report Date: 09/23/2021
Date Signed: 09/23/2021 10:08:23 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:	SMITH, JULIE MARIE		FACILITY NUMBER:	434415230
ADMINISTRATOR:	SMITH, JULIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 207-5640
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94085
CAPACITY:	14	CENSUS: 3	DATE:	09/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Julie Marie Smith		TIME COMPLETED:	10:20 AM

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) Mel Matos met with Julie Marie Smith, Licensee, for unannounced Required – 1 year annual inspection (KIT 2). LPA was granted access to the home by the Licensee. LPA also observed three preschool children in the home during today's inspection. The Licensee was operating within her capacity and ratio requirements. LPA observed the required postings, including the facility license, near the front entrance to the home. Days and hours of operation are Monday - Friday from 8:30 AM to 1 PM. The Licensee and her fiance (Ryan Ketterson) are the adults residing in the home. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on July 28, 2021. The Licensee has the required vaccinations (MMR, Tdap, & flu) and is current with the Mandated Reporter Training for Child Care Workers. The Licensee's CPR and First Aid certifications expired on February 10, 2021 and are thus not current. Safe sleep update: LPA discussed the new “Safe Sleep” regulations with the Licensee and provided a copy of the regulations, including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee. LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects. LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heater units inside the home. There are no stairs inside the home. Off limit areas inside the home: three bedrooms, kitchen, barricaded fireplace unit, and attached garage. Off limit areas outdoors: left side entry area of the backyard.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

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: SMITH, JULIE MARIE	FACILITY NUMBER: 434415230
	VISIT DATE: 09/23/2021

NARRATIVE

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LPA observed a fully charged 2A10BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she does not have any weapons in the home. The Licensee has two dogs in the home (Chiuhua & Cocker Spaniel) in the home that are vaccinated/licensed. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Any poisons are locked and inaccessible to the day care children. The Licensee states that she does not administer any medication to the day care children at this time.

A review of staff records on September 21, 2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded the Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Supervision of children was discussed with the 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. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time without two fully qualified adults present. The Licensee states that does not transport any day care children. The 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.

The following deficiency is issued on the attached page (809-D) as a result of today's inspection. LPAs conducted an exit interview with the Licensee prior to the conclusion of today's inspection and provided her with copies of appeal rights.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

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: SMITH, JULIE MARIE	FACILITY NUMBER: 434415230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/25/2021 Section Cited	1 2 3 4 5 6 7	Personnel Requirements: The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
	8 9 10 11 12 13 14	This requirements was not met as evidenced by: The Licensee's CPR and First Aid certifications expired on February 10, 2021. This presents a potential risk to the health/safety 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: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

LIC809 (FAS) - (06/04)

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