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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416115
Report Date: 05/12/2022
Date Signed: 05/12/2022 10:51:58 AM


Document Has Been Signed on 05/12/2022 10:51 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:ARMENTA, JIMFACILITY NUMBER:
434416115
ADMINISTRATOR:JIM ARMENTAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 477-6477
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:14CENSUS: 6DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:13 AM
MET WITH:Jim ArmentaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Janette Cruz met with Jim Armenta, Licensee, for unannounced Required 1-year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed, Licensee's adult assistant, Tina Nguyen (aka Anh Hong Nguyen), and six preschool day care children present in the home during today's inspection. The Licensee was operating within his capacity and ratio requirements. LPA observed the required postings, including the facility license, posted inside the home. Days and hours of operation are Monday - Friday from 7:30 AM to 6:00 PM. Licensee stated he is the only adult who is currently residing in the home. There are no active waivers for this facility. Licensee has current CPR and First Aid certifications (expiration: 08/26/2023).

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 12/02/2021. Licensee has an active Child Care Liability Insurance valid until 3/11/2023. Licensee has the required vaccinations (MMR, Tdap, & flu opt-out) and is current with the Mandated Reporter Training for Child Care Workers (expiration: 06/02/2023). LPA reviewed ten children's files which were complete with the required forms.

LPA discussed the safe sleep regulations with the 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 the 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.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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: ARMENTA, JIM
FACILITY NUMBER: 434416115
VISIT DATE: 05/12/2022
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LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Licensee states that a child will be isolated in day-care bedroom #1 of the home if necessary due to illness or communicable disease.

LPA observed the home is clean, orderly, and safe for the day care children. LPA also observed a screened fireplace. There are no open face heater units and stairs inside the home. Off limit areas inside the home: bedroom 2, bathroom 2, and the garage (per facility sketch). Off limit areas outside the home: entire backyard.

LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that he does not have any weapons and pets in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. All poisons are stored in high cabinets. The Licensee states that he does not administer medication to the day care children.

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

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.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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: ARMENTA, JIM
FACILITY NUMBER: 434416115
VISIT DATE: 05/12/2022
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Supervision of children was discussed with Licensee and he understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands his capacity options and he understands that he cannot have more than 14 children in the home at any time without a fully qualified adult present. Licensee states that he does not transport any day care children. The Licensee understands 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.

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.

LPA provided Licensee with website resources on managing food allergies at school and handling medical emergencies related to food allergies.

CDC Managing Food Allergies at School
https://www.cdc.gov/healthyschools/foodallergies/index.htm

American Academy of Pediatrics Healthy Children Medical Emergencies
https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/When-to-Call-Emergency-Medical-Services-EMS.aspx

Exit interview conducted and report was reviewed with the Licensee, Jim Armenta. A deficiency was cited during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/12/2022 10:51 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: ARMENTA, JIM
FACILITY NUMBER: 434416115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.2(b)

102416.2(b) Reporting Requirements. The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Licensee confirmed that he and three children enrolled contracted COVID around December 2020 and Licensee had to shut down the facility for two weeks but was not able to notify the Department at that time which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2022
Plan of Correction
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Licensee will submit to LPA a statement of understanding of child care reporting requirements as per regulations by POC date 05/26/2022.
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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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