434416049-3-11-2022-07-CC-DVIA-CCEQUS-20220311112912

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416049
Report Date: 03/11/2022
Date Signed: 03/11/2022 11:29:24 AM

Document Has Been Signed on 03/11/2022 11:29 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:	BUGARIN, SANDRA		FACILITY NUMBER:	434416049
ADMINISTRATOR:	SANDRA BUGARIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 685-7090
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	14	CENSUS: 0	DATE:	03/11/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Sandra Bugarin		TIME COMPLETED:	11:40 AM

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 Analyst (LPA) Deanna Villagrana met with applicant Sandra Bugarin to conduct an announced pre-licensing inspection to the home today. The adults that reside in the home are the Applicant and her husband, with two children ages 17 and 10 years old. Days and hours of operation will be Monday - Friday from 7:30 AM to 5:30 PM. Applicant has completed her Preventative Health and Safety Child Care Training on and completed additional lead training on 01/20/2022. Applicant's CPR and First Aid certifications are current and expire on 09/15/2023. Applicant rents the home and the Owner/Landlord Notification form LIC9149 is on file. Applicant does not have liability insurance and will issue affidavit regarding liability insurance for FCCH. Licensee completed Mandated Reporter Training on 01/18/2021 and has current immunization against pertussis, measles and influenza on file. LPA toured the indoor and outdoor areas during today's visit. LPA observed barricaded stairs and fireplace in the home. Off limit areas inside the home: two bedrooms located upstairs, downstairs master bedroom/bath, one bedroom that is located to the far right of the hallway and attached garage. LPA observed a fully charged 2A10BC fire extinguisher, working combo smoke and carbon monoxide fenced backyard, and no bodies of water. Off limit areas outdoor: right side yard including storage. Applicant states that there are no weapons in the home. Licensee states she has one dog that will stay in the garage or upstairs with her children and is vaccinated. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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: BUGARIN, SANDRA	FACILITY NUMBER: 434416049
	VISIT DATE: 03/11/2022

NARRATIVE

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A review of staff records on 03/04/2022 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Sandra Bugarin was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 reviewed with Sandra Bugarin the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Forms of discipline used by Applicant: talking to children, timeout and redirection. Applicant understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

LPA discussed the safe sleep regulations with Sandra Bugarin 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 Sandra Bugarin 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.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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: BUGARIN, SANDRA	FACILITY NUMBER: 434416049
	VISIT DATE: 03/11/2022

NARRATIVE

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LPA discussed the requirements of AB 633 with the Applicant and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Applicant understands the requirements. LPA also discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, 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. SB 792 Immunization Requirements was also discussed. Applicant's immunization records are on file.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with applicant Sandra Bugarin. LPA informed applicant a large license is pending Manager's approval.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

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