434415671-8-5-2021-07-CC-JCRZ-C5LVFB-20210805162336

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415671
Report Date: 08/05/2021
Date Signed: 08/05/2021 04:23:48 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: 7	DATE:	08/05/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Mayra Gama		TIME COMPLETED:	04:45 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 (LPA) Janette Cruz met with Mayra Gama and Toni Serrano, Licensees, for an unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensees. LPA also observed one adult assistant and seven children (1 infant, 6 preschool) in the home during today's inspection. The Licensees were operating within their capacity and ratio requirements during today's inspection. LPA observed the required postings, including the facility license, near the front entrance to the home. The home has a working telephone (408) 509-4044. Days and hours of operation are Monday - Thursday from 7:30AM to 5:30 PM, Fridays from 7:30AM - 5:30PM. The Licensees and Mayra’s mother, Susana Castillo, are the adults residing in the home. The Licensees' CPR and First Aid on file expire on 10/2021. 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 02/09/21. The Licensees have the required vaccinations (MMR, Tdap, & flu). The Licensee’s Mandated Reporter Training for Child Care Workers on file expire on 09/09/2021(Mayra) 08/28/2021(Toni Romero). LPA reviewed seven children's files and observed current and updated Identification and Emergency Information (LIC 700) and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. The Licensees state that a child will be isolated in the dining room area if needed to because of illness or communicable disease. LPA discussed the new “Safe Sleep” regulations with the Licensees and provided a copy of the regulations, including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee. REPORT CONTINUED ON FOLLOWING PAGE #2 - REPORT DATED 08/5/2021):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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: GAMA, MAYRA & SERRANO, TONI	FACILITY NUMBER: 434415671
	VISIT DATE: 08/05/2021

NARRATIVE

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LPA reminded the Licensees 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. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly with heating and ventilation for safety and comfort of children. LPA observed a screened fireplace unit in the home. Off limit areas inside the home: 3 bedrooms, and attached garage. Off limit areas outside the home: left side section and storage area of the backyard. LPA observed an air conditioner condenser unit on the right side of the backyard that is accessible to children. Licensees state that the A/C condenser is brand new and a mesh cover has already been ordered for children's safety. LPA also observed that the attached garage is under construction. Licensees state that the garage will be converted to an ADU. Licensees provided a copy of City of San Jose permit for the construction. Licensees state that they were not able to report to the department when construction started in July 2021. LPA observed construction tools on the ground that are accessible to children. Licensees states that construction is only done during weekends and not during day care hours. Licensees states that they have been supervising children to prevent going to the area near the construction. Licensee states that they will put a safety gate or partition between the children's play area and the side affected by construction at the backyard and make sure construction tools are not accessible. LPA observed no bodies of water.

LPA observed a fully charged 2A10BC fire extinguisher and working smoke/carbon monoxide detectors. LPA observed the Licensees have a pet ( Labrador Retriever dog) in the home. Licensees state that pet is vaccinated. Licensees state that there are no weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. LPA observed any poisons are locked in the attachedgarage inaccessible to the day care children.
REPORT CONTINUED ON FOLLOWING PAGE #3 - REPORT DATED 08/05/2021):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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: GAMA, MAYRA & SERRANO, TONI	FACILITY NUMBER: 434415671
	VISIT DATE: 08/05/2021

NARRATIVE

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A review of staff records on 08/05/21 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 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 Licensees 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 understand that they cannot have more than 14 children in the home at any time without a fully qualified adult present. The Licensees state that they do not transport any day care children. The Licensees understand 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.

Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA conducted an exit interview with the Licensees and advised a Type B deficiency is cited during today's inspection (See page LIC809-D). Licensee agreed to have the following items submitted to LPA Cruz by Friday August 19, 2021:
1. Proof of safety cover for the A/C Condenser unit
2. Proof of safety gate / partition separating children play area and construction affected area on the right side of backyard

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/05/2021 Section Cited	1 2 3 4 5 6 7	102416.3(a)(2)Alterations to Existing Buildings 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: (2) Room additions to the family child care home. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on observations, interviews and record reviews, Licensees state that they were not able to report to the Department regarding the garage conversion into an ADU.	8 9 10 11 12 13 14
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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: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

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