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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416384
Report Date: 08/26/2021
Date Signed: 08/26/2021 12:07:52 PM

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:CAIMOL, ANISIAFACILITY NUMBER:
434416384
ADMINISTRATOR:CAIMOL, ANISIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 788-6723
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:14CENSUS: 6DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Anisia Caimol, LicenseeTIME COMPLETED:
12:17 PM
NARRATIVE
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#2 Licensing Program Analyst (LPA), James Santos conducted an unannounced Required 1 Year Inspection today. LPA met with Licensee, Anisia Caimol. There were six (6) children in the home who are between 2 - 4 years old. There are 4 people residing in the home: Licensee, her husband and their daughter (13 years old) and the Landlord.

LPA toured the home inside and out with the Licensee. The home was observed to be clean and in good order. There are sufficient toys and play equipment for the day care children. Bathroom used by children was observed to be clean and in good condition. Per Licensee, there are no weapons and poisons in the home. The home has fire extinguisher, carbon monoxide and smoke detector and first aid kit. The fireplace is observed to be barricaded. Off limit areas in the home: all four bedrooms, hall bathroom, kitchen and garage.

Off limit area outside the home is a locked storage shed. The outdoor playground area is surrounded and enclosed by a fence. Both playground and backyard areas were observed to be well maintained and free of hazards. The playground equipment were observed to be in good condition. There are no bodies of water observed.

LPA obtained an updated copy of the roster of children in care. Children's records were reviewed which include Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice and Immunization record.

Staff records were reviewed which include fingerprint clearance, TB clearance, immunization (Measles, Pertussis, and Flu) record, CPR/First Aid and Mandated Reported Training.

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SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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 3
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: CAIMOL, ANISIA
FACILITY NUMBER: 434416384
VISIT DATE: 08/26/2021
NARRATIVE
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Per review of record, Staff (S1) has not completed the AB1207 Mandated Reporter Training. LPA discussed with Licensee Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed. Licensee stated that she's not planning to provide IMS at this time.

Per review of the fire/disaster drill log, the last drill was conducted in May 2021.



LPAs reviewed with Licensee the violations that would result in an immediate assessment of civil penalty in the amount of $500. Care providers are encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Adoptions of new laws, pay annual fees etc.


As a result of this inspection, a deficiency was cited. See LIC809D page for deficiency.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: CAIMOL, ANISIA
FACILITY NUMBER: 434416384
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
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This requirement was not met as evidenced by: Per review of record, Staff (S1) has not completed the AB1207 Mandated Reporter Training. This poses a potential risk to the health and safety of children in care.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3