434415671-8-14-2019-07-CC-MSMS-BF2UVJ-20190814155514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415671
Report Date: 08/14/2019
Date Signed: 08/14/2019 03:55:20 PM

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:	GAMA, MAYRA & SERRANO, TONI		FACILITY NUMBER:	434415671
ADMINISTRATOR:	GAMA, MAYRA & SERRANO, TON		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 613-2556
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95111
CAPACITY:	14	CENSUS: 12	DATE:	08/14/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Mayra Gama & Toni Serrano		TIME COMPLETED:	04:15 PM

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 Analysts (LPAs) Mel Matos and Dung Mac met with Mayra Gama, co-Licensee, for unannounced annual/random inspection. LPA also observed one adult assistant (Licensee's sister) and twelve day care children (1 infant, 8 preschool, 1 school age child, and Mayra's two children (age 3 & 9 years) in the home during today's inspection. Days and hours of operation are Monday - Friday from 7:30 AM to 5:30 PM. The Licensees and Mayra's mother are the adults residing in the home. Mayra states that Toni also has a 7 year old child residing in the home. LPAs reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on February 16, 2019. The Licensees have current CPR & First Aid certifications (expiration: 10/2019). One adult assistant (Licensee's sister) also has current CPR & First Aid certifications (expiration: 02/16/2020). LPAs observed that the Licensees have record of MMR & Tdap vaccinations on file. The Licensees state that they will submit copies of opt out forms for the flu vaccine to the Department. LPAs reviewed ten children's files and observed current forms, including updated immunization records and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. LPAs also reviewed one staff file during today's inspection and the file is complete. LPAs toured the indoor and outdoor areas of the home during today's inspection. The Licensees have a working telephone in the home. LPAs observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPAs did not observe any wall heaters inside the home. There are no stairs inside the home. Off limit areas inside the home: three bedrooms, attached garage, barricaded fireplace, 1 kitchen cabinet, and 4 bathroom vanity cabinets. Off limit areas outside the home: left side section, barricaded air conditioner unit, and storage area of the backyard. LPAs observed a fully charged 2A10BC fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water during today's inspection. Mayra states that they do not have any weapons in the home. The Licensees have one dog (Terrier) that is vaccinated and kept in the off limits areas of the backyard. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Mayra states that they do not administer any medication to the day care children. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 08/14/2019):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019

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: GAMA, MAYRA & SERRANO, TONI	FACILITY NUMBER: 434415671
	VISIT DATE: 08/14/2019

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 08/14/2019):

A review of staff records on August 8, 2019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPAs also reminded Mayra 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 they understand that they must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensees understand their capacity options and they understand that they cannot have more than 14 children in the home at any time when at least two qualified adults are present in the home. The Licensees state that they don't employ any assistants in the day care. LPAs reminded Mayra that her two children (ages 9 & 3 years) and Toni's 7 year old child count against the licensed capacity whenever they are present in the home. Mayra states that she transports children on field trips a few times per year. Mayra understands that children shall never be left unattended in a vehicle.

LPAs reminded the Licensees that effective January 1, 2019 Assembly Bill 2370 requires that all licensed homes to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPAs provided a copy of the “Lead Poisoning Facts Information Flyer” to the Licensees. Safe sleep information & handout was also discussed with Mayra.

No deficiencies issued during today's inspection.

LPAs conducted an exit interview with Mayra prior to the conclusion of today's inspection and Mayra agreed to submit the following items to LPA Mac by Friday August 23, 2019: 1) Updated Application for a Family Child Care Home (LIC 279), Current Children in Your Home (LIC 279B), Updated Emergency Disaster Plan (LIC 610A), opt out of flu vaccines for both Licensees, and copies of proof of completion of the Mandated Reporter Training for Child Care Workers for both Licensees.

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: 08/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019

LIC809 (FAS) - (06/04)

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