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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415847
Report Date: 05/11/2022
Date Signed: 05/12/2022 11:16:19 AM


Document Has Been Signed on 05/12/2022 11:16 AM - 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:AVALOS, MARIA DEL CARMEN & CERNA, JUANAFACILITY NUMBER:
434415847
ADMINISTRATOR:AVALOS, MARIA DEL CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 346-2243
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 13DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Maria Del Carmen Avalos and Juana "Joanna" CernaTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 1 Year inspection. LPA met with Licensees Maria Del Carmen Avalos and Juana "Joanna" Cerna and explained the reason for the inspection. The San Jose Regional Office also conducted a virtual informal meeting on 11/08/2021 due to staffing ratio and capacity. Present during today's inspection were Licensee Maria, Licensee Joanna, and 13 children, whom 4 were infant age. Licensee Maria stated that she enrolled her son into kindergarten, but he is not yet attending kindergarten. LPA discussed and provided Licensees the regulations for school-age children. LPA explained that per the Health and Safety code that a school-age children would have to be enrolled and attending kindergarten. Facility was not within ratio during today's inspection.

License, emergency disaster plan, and notification of parent's rights were posted. There is working phone at the facility. The hours of operation are Monday through Friday 7AM to 5PM.

LPA toured the inside and outside of the home. The off-limit areas of the home are the 1st living room, two bedrooms, bedroom between bedrooms, master bedroom and bathroom, kitchen, garage, and the left side of the home. There are fireplaces in the home, which are barricaded. Disinfectant, cleaning supplies, and other items that are dangerous to children were inaccessible. There are age appropriate toys and equipment for children. There are play yards for children. There were no baby bouncers observed during today's inspection. Licensee stated that there are no weapons, such as firearms, stored in the home. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire drill was conducted on 03/02/2022.

------------------------------continues on 809 dated 05/11/2022 page 2----------------------------
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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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: AVALOS, MARIA DEL CARMEN & CERNA, JUANA
FACILITY NUMBER: 434415847
VISIT DATE: 05/11/2022
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---------------------continuation of 809 dated 05/11/2022 page 1--------------------------------

The backyard is used and is fenced. There is swing set, which is not anchored to the ground. Licensee Joanna stated that she will get weights to anchor it to the ground. Licensee stated that she will send proof to Licensing. There were no bodies of water observed during today's inspection.

Licensee stated that they will physically check that children are sleeping, but does not document the time that they checked. Licensee stated that she will start documenting the time and send proof to Licensing. LPA also discussed with Licensee that the door needs to be open when the children are sleeping. 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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. The child does not have written permission from the parent for Licensees to administer medication. Licensees stated that they will obtain written permission from parents and send proof to Licensing. For IMS information , see PIN 22-02-CCP. A Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm



-----------------------continues on 809 dated 05/11/2022 page 3-------------------------------------
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: AVALOS, MARIA DEL CARMEN & CERNA, JUANA
FACILITY NUMBER: 434415847
VISIT DATE: 05/11/2022
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--------------------------continuation of 809 dated 05/11/2022 page 2-----------------------------

A copy of the facility roster was obtained. 12 children's files were reviewed. The records reviewed include but not limited to parent's rights and immunization records. LPA discussed with Licensees about ensuring that all forms are filled out and signed by parents.

Licensees' files were reviewed. Licensees both have valid CPR/1st Aid, which expires on 06/212023. Licensees both completed the Mandated Reporter training on 03/30/2021.

The adults 18 and living in the home are both Licensees, and Licensee Maria's spouse. All adults have cleared criminal record, child abuse index, and TB test. 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.

As a result of this inspection, two type A and three type b citations have been issued. Exit interview conducted and report was reviewed with the licensees Maria Avalos and Joanna Cerna. 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.

LPA Samantha Yip informed licensees Maria and Joanna that this report dated 05/11/2022 documents two type A citations which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Samantha Yip informed the licensees to provide a copy of this licensing report dated 05/11/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/12/2022 11:16 AM - 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: AVALOS, MARIA DEL CARMEN & CERNA, JUANA
FACILITY NUMBER: 434415847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(g)
Staffing Ratio and Capacity
(g) For the purpose of meeting the criteria in Sections 1597.44 and 1597.465 of the Health and Safety Code, for a school age child who is under age six, the licensee shall maintain documentation verifying the
child’s enrollment and attendance at kindergarten, including transitional kindergarten, or elementary
school.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited. Licensees had 13 children; one child is enrolled in kindergarten, but not attending, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Licensees stated that they submitted written plan on how they will be in complicance with ratio.
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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 05/12/2022 11:16 AM - 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: AVALOS, MARIA DEL CARMEN & CERNA, JUANA
FACILITY NUMBER: 434415847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Licensees had the door closed to where infants were sleeping, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2022
Plan of Correction
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Licensees stated that they will submit a written statement that they have read and understand the safe sleep regulations.
Type B
Section Cited
CCR
102425(j)(5)(A)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. The provider shall be able to visually observe the infant without moving the door.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Licensee have a crack in the door and curtains that cover the window, which they have to open or move in order to see the children, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2022
Plan of Correction
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Licensees stated that they will submit a written statement that they have read and understand the safe sleep regulations.

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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 05/12/2022 11:16 AM - 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: AVALOS, MARIA DEL CARMEN & CERNA, JUANA
FACILITY NUMBER: 434415847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record reviews, the licensee did not comply with the section cited above. Licensees physically check the children, but do not document the time that they check the children, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2022
Plan of Correction
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Licensee will submit chart used to document sleeping infants.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 05/12/2022 11:16 AM - 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: AVALOS, MARIA DEL CARMEN & CERNA, JUANA
FACILITY NUMBER: 434415847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(2)(b)
For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either:A large family day care home may provide care for more than 12 children and up to and including 14 children, if all of the following conditions are met: No more than three infants are cared for during any time when more than 12 children are being cared for.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee had 13 children and four infants, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Licensee will submit plan on how she will be compliance with ratio.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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3
4

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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7