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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415272
Report Date: 04/21/2023
Date Signed: 04/21/2023 01:06:29 PM


Document Has Been Signed on 04/21/2023 01:06 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:ELIZALDE, YESSICAFACILITY NUMBER:
434415272
ADMINISTRATOR:ELIZALDE, YESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 903-9413
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:14CENSUS: DATE:
04/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Yessica ElizaldweTIME COMPLETED:
01:26 PM
NARRATIVE
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On 04/212023 at 08:37AM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Yessica Elizalde, for an annual inspection and explained the reason for the visit to her. Present during today's visit were licensee, assistant Tania with 3 children, one is licensee child: one (1) infants and two preschool age, additional (1) infant child arrived during site visit. Adults living in the home are licensee, her spous and adult niece Marita and licensee two minor children. Days and hours of operation are Monday through Friday 07:00 AM to 5:30 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 4/19/2023 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 to story home. LPA observed a glass covered fireplace, no wall heater, opened barricaded stairs, and no bodies of water. LPA observed two playrooms are room additions leading to the backyard from the home. LPA observed a off limit master bedroom being used as a day care room for napping and play area. Licensee stated there are no weapons. Licensee stated she no pets. LPA observed a 3A40BC fire extinguisher last serviced 07/25/2022. A combination Carbon Monoxide/smoke detector is operable. Sharp objects, medicines, poisons, and cleaning supplies were inaccessible to the children in care. Off limit areas inside the home: the entire upstairs which consists of three bedrooms and one bathroom, and the garage. On limit areas: kitchen, living room, master Bedroom, and downstairs bathroom. On limit areas outside the home: rear back yard. Off limit outside: gated left and right side back yard area.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to her license. Licensee stated she does 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 report dated 04/21/2023 pg. 1/2
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
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 04/21/2023 01:06 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: ELIZALDE, YESSICA
FACILITY NUMBER: 434415272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(3)
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: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview), the licensee did not comply with the section cited above in gate door was open on stairs leading to upstairs bedrooms during site visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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Licensee closed gate door leading to upstairs bedroom during site visit.
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) (record review)], the licensee did not comply with the section cited above in last fire/disaster drill performed on 8/11/2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Licensee will submit a copy of completed fire/disaster drill log to the San Jose Regional Office by close of business 05/05/2023.
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: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 10


Document Has Been Signed on 04/21/2023 01:06 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: ELIZALDE, YESSICA
FACILITY NUMBER: 434415272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in, Off limit downstairs bedroom is being used for day care use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Licensee will submit a written of her understanding of the Title 22 regulation to the
San Jose Regional Office by close of business 5/05/2023.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Child 5 is missing from the Facility Roster which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee will submit a copy of updated facility children roster to the San Jose Regional Office by close of business 4/24/2023.
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: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 10


Document Has Been Signed on 04/21/2023 01:06 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: ELIZALDE, YESSICA
FACILITY NUMBER: 434415272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
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: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Child 2 (C2), C3 missing 15-minute sleep check which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Licensee will submit copies of 15 minute safe sleep check with a written statement she understands the Title 22 infant sleep regulations to the San Jose Regional Office by close of business 05/05/2023.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 10


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: ELIZALDE, YESSICA
FACILITY NUMBER: 434415272
VISIT DATE: 04/21/2023
NARRATIVE
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Continuation of report dated 04/21/2023 pg. 2/2
LPA observed Child 6 is missing from the roster of the children. LPA observed a fire and disaster drill log last performed on 08/11/2022. LPA reviewed 5 children’s files and observed Child 2 (C2) and C3 missing Infant 15-minute check sleep log. LPA observed licensee completed Mandated Reporter Training on 07/21/22, assistants Tania completed 07/21/22, and Maria completed 02/27/2023. Licensee has Pediatric CPR/1st Aid that expiring on 12/05/2024, assistants Tania expires 03/28/2024 and Maria expired 2/13/23. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is current for licensee, and all adults helping or residing in the home.

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 currently. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

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 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.

Type B deficiencies were cited during today's visit. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.


Exit interview conducted and report was reviewed in Spanish with the licensee, Yessica Elizalde. 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: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC809 (FAS) - (06/04)
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