<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416362
Report Date: 02/24/2022
Date Signed: 03/08/2022 10:45:40 AM


Document Has Been Signed on 03/08/2022 10:45 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:PEREZ, MAYELIFACILITY NUMBER:
434416362
ADMINISTRATOR:PEREZ, MAYELIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
4084829136
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:14CENSUS: 0DATE:
02/24/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Perez MayeliTIME COMPLETED:
11:30 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
LPA toured the indoor and outdoor areas during today's inspection. Off limit areas are the garage, Master bedroom and bath , bedroom #2, utility room, the sides of the house are secured by a gate and fence. LPA observed fire pull station, a fully charged fire extinguisher, working smoke detectors, and working carbon monoxide detectors. Fireplace in the home is safe guarded by fireplace barrier (child safety gate) . Fire clearance granted 2/14/2022

The backyard is fenced and there are no bodies of water. There is play equipment that is in good condition and available for the children to use. Cleaning products, medications, sharp objects and other similar items are stored inaccessible to children. LPA advised Licensee that poisons need to be locked at all times. LPA reminded the Licensee that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in family childcare homes.

Licensee has an area in the entry way for posting required documents. There are sufficient toys and materials for the children. There is sufficient tables and chairs for activities as

Licensee will be using talking, redirection, and timeout for discipline. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Discussed isolation of sick children, supervision of children, capacity options, transportation of children, LPA reviewed with licensee Mayeli Perez 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.

Licensee Mayeli Perez 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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Stephanie CollinsTELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: PEREZ, MAYELI
FACILITY NUMBER: 434416362
VISIT DATE: 02/24/2022
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
26
27
28
29
30
31
32
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
Safe Sleep
LPA discussed the safe sleep regulations with licensee Mayeli Perez 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 Mayeli Perez 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.

Posting Requirements
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit Interview
Exit interview conducted and report was reviewed with the licensee Mayeli Perez .

Pending Management's final review and approvael

Pending Document:
Assistant Maria Amado : Proof of Tdap
Husband: Juan G Tellez : Proof of TB clearance
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Stephanie CollinsTELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2