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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415242
Report Date: 11/08/2022
Date Signed: 11/08/2022 02:46:56 PM


Document Has Been Signed on 11/08/2022 02:46 PM - 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:BUENO DE ARCINIEGA, ELAUTERIAFACILITY NUMBER:
434415242
ADMINISTRATOR:BUENO, ELAUTERIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 387-4578
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:14CENSUS: DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Elauteria BuenoTIME COMPLETED:
03:00 PM
NARRATIVE
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On 11/08/2022 at 9:26 AM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Elauteria Bueno, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee, licensee spouse Vicente, adult son Jonathan and adult nephew JoseSantos with 7 children: six preschool and one infant Assistant Jessica arrived at 10 AM. Adults living in the home are licensee, her spouse, adult son Jonathan and nephew Jose Santos. Days and hours of operation are Monday through Friday 6:00 AM to 6:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 11/07/2022 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 fireplace closed off inside the home, no wall heater, barricaded stairs and no bodies of water. Licensee stated there are no weapons. Licensee stated they have no pets. LPA observed a fully charged 2A10BC fire extinguisher that has not been serviced in two years. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children in care. Off limit areas: all of second floor, Garage, bedroom 2 and 3. Off limit outside: enclosed left side back yard. Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 12 children according to their license. Licensee stated they do not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size. Continues on report dated 11/08/2022

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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Document Has Been Signed on 11/08/2022 02:46 PM - 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: BUENO DE ARCINIEGA, ELAUTERIA
FACILITY NUMBER: 434415242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above, fire extinguisher has not been serviced in two years, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2022
Plan of Correction
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Licensee will submit proof of service or replacement of approved fire extinguisher by close of business to the San Jose Regional Office by close of business 11/23/2022.
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 observation, interview and record review, the licensee did not comply with the section cited above, last fire drill was conducted on 03/16/2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2022
Plan of Correction
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Licensee will provide copy of conducting fire drill to the San Jose Regional Office by close of business 11/23/2022.

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 SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2022 02:46 PM - 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: BUENO DE ARCINIEGA, ELAUTERIA
FACILITY NUMBER: 434415242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above, safe sleep log missing for C1, C2 and C5, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Licensee will provide copies of sleep logs for C1, C2, and C5 by close of business 11/28/2022.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above, assistants Jonathan Arciniega and Vicente Arciniega have not completed Mandated Reporter Training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will submit proof of completion of Mandated Reporter Training for assistants, Jonathan and Vicente to the San Jose Regional Office by close of business 12/02/2022.

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 SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2022 02:46 PM - 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: BUENO DE ARCINIEGA, ELAUTERIA
FACILITY NUMBER: 434415242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above, C5 file has missing Individual Infant Sleeping Plan LIC 9227 in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Licensee will submitt a copy of completed LIC 9227 for C5 by close of business to the San Jose Regional Office 11/28/2022.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above C1, C2, C5 file missing log, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Licensee will provide copy of log for C1, C2 and C5 to the San Jose Regional Office by close of business 11/28/2022.

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 SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 8


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: BUENO DE ARCINIEGA, ELAUTERIA
FACILITY NUMBER: 434415242
VISIT DATE: 11/08/2022
NARRATIVE
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Continuation of report dated 11/08/2022 pg. 2/2
LPA observed a fire and disaster drill log that was last conducted on 03/16/2022. LPA reviewed 5 children’s files and observed C1, C2 and C5 were missing safe sleep logs, C5 missing Individual Infant Sleeping Plan LIC9227 . The 15 minute check sleep log for infants under 24 months was discussed. LPA observed that the Licensee has Mandated Reporter training, training was completed on 10/15/2021, assistants Jessica Flores completed 11/06/2021, assistant Jonathan Arciniega and Vicente Arciniega have not completed Mandated Reporter Training. Licensee has Pediatric CPR/1st Aid expiring 08/2023, assistants Sandra expiring 8/2023, Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee and assistants. Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS 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. see PIN 22-02-CCP.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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 for 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.

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.

The following B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. Technical assistant provided for rear left fence. Exit interview conducted and report was reviewed in Spanish with the licensee, Elauteria Bueno. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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