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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416205
Report Date: 09/13/2022
Date Signed: 09/13/2022 05:51:01 PM


Document Has Been Signed on 09/13/2022 05:51 PM - 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:SUTACHAN, JEIMYFACILITY NUMBER:
434416205
ADMINISTRATOR:JEIMY SUTACHANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 309-2128
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:14CENSUS: DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Jeimy SutachanTIME COMPLETED:
05:50 PM
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On 09/13/2022 at 2:26 PM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Jeimy Sutachan, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee and assistant and adult nephew with 10 children: seven preschool and three infants. Adults living in the home are licensee and her nephew Nicolas Triana who is visiting since 08/31/2022. Days and hours of operation are Monday through Friday 8:00 AM to 5:00 PM.
A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 09/12/2022 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. 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.

LPA inspected inside and outside of the home. LPA observed fireplace closed off inside the home, no wall heater, no stairs and no bodies of water. Licensee stated there are no weapons. Licensee stated they have no pets. LPA observed a new and fully charged 2A10BC fire extinguisher. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Off limit areas: Garage, kitchen, room 2 and 3. Off limit outside: enclosed left and right side back yard. Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 12 children according to their license. Licensee stated they do not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size. Continues on report dated 09/13/2022

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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: SUTACHAN, JEIMY
FACILITY NUMBER: 434416205
VISIT DATE: 09/13/2022
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Continuation of report dated 09/13/2022 pg. 2/2
LPA observed a fire and disaster drill log that was last conducted on 08/10/2022. LPA reviewed 10 children’s files and observed all required documentation was in compliance. The 15 minute check sleep log for infants under 24 months was discussed, licensee provided completed sleep logs, LPA reviewed and observed they were in compliance. LPA observed that the Licensee has Mandated Reporter training, training was completed on 08/01/2021, assistants Sandra Arboleda completed 7/31/2021 and Heidy Suarez Espinoza 11/18/2021. Licensee has Pediatric CPR/1st Aid expiring 05/29/2023, assistants Sandra expiring 8/7/2023 and Heidy expiring 10/15/2023. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee and assistants.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

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.

No deficiencies were cited during today's visit. Technical assistant provided for rear right fence. Exit interview conducted and report was reviewed in Spanish with the licensee, Jeimy Sutachan. 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.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
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