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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416683
Report Date: 06/28/2021
Date Signed: 06/29/2021 08:10:09 AM

Document Has Been Signed on 06/29/2021 08:10 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:ONE WORLDFACILITY NUMBER:
434416683
ADMINISTRATOR:ANNA SIFUENTESFACILITY TYPE:
850
ADDRESS:8387 WREN AVENUETELEPHONE:
(408) 842-4148
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 38TOTAL ENROLLED CHILDREN: 0CENSUS: 20DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Anna SifuentesTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required 1 Year inspection. LPA met with Licensee Anna Sifuentes and explained the reason for the inspection. Present upon arrival were 20 children and 4 staff. Facility was in ratio during today's inspection.

There is a board to post required postings. LPA reviewed sign in/sign out sheet, which contains full legal signature. There is working phone on the facility.

LPA toured the inside and outside of the facility with Licensee. The facility was observed to be clean. All toys and equipment were observed to be in good condition and age-appropriate. LPA inspected the children's restroom. Licensee stated that the children's bathroom is currently being renovated. Children are using the women's/staff restroom. LPA observed that there was a bag of cement in the bathroom. LPA reminded Licensee that anything that states to keep out of reach of children need to be inaccessible, such as disinfectant wipes. The bag of cement and disinfectant were moved to an inaccessible area during today's inspection. LPA inspected the children's restroom being renovated and observed that there were tools in the bathroom. Licensee placed a gate in front of the children's bathroom during today's inspection. There is fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire drill was conducted on 06/08/2021. Licensee stated that there are no weapons, such as firearms, stored in the home. LPA reminded Licensee that children need to be supervised at all time, including during naptime.

The outdoor activity area is fenced. There is shaded rest area for the children. Area around play structures have resilient material. LPA reminded Licensee to rack tan bark below swings and any climbing structure were it is low. Licensee has extra tan bark that she is planning on putting down. LPA did not observe any bodies of water during today's inspection.

----------------------CONTINUES ON 809 DATED 06/28/2021 PAGE 2------------------------------
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2021
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: ONE WORLD
FACILITY NUMBER: 434416683
VISIT DATE: 06/28/2021
NARRATIVE
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-------------------CONTINUATION OF 809 DATED 06/28/2021 PAGE 1----------------------------

Facility only provides snacks to children. Menu was observed to be posted. All meals are prepared and brought from home. Drinking water is provided through individual water bottles. Licensee does not currently provide Incidental Medical Services.

A copy of the facility roster was obtained. 10 children's file were reviewed. The records reviewed include but not limited to emergency contact and medical assessment.

4 staff files were reviewed. The records reviewed include but not limited to health screening, Mandated Reporter training, and immunization records. There is at least one staff who has a valid CPR/1st Aid, which expires on 03/15/2023. LPA reminded Licensee that immunization records for pertussis, measles, and influenza needs to be in file.

LPA reviewed Facility Personnel Report Summary dated 06/24/2021. LPA observed that S-1 and S-2's fingerprints were not cleared. Licensee understands that staff cannot start working until their fingerprints are cleared and associated. All other staff present have cleared criminal record and child abuse index clearance.

In area that were evaluated, a Type A citation was cited and civil penalty of $200 was issued. An exit interview was conducted where this report, citation, plan of correction, civil penalty, and appeals rights were discussed and provided to Licensee Anna Sifuentes.

LPA also discussed about AB 633 requirement to provided a copy of 809 report dated 06/28/2021 and obtain a signed copy LIC 9224 for each child in care within one business days. LPA also discussed with Director that a copy of this report and a signed copy of LIC 9224 is required for any newly enrolled children within the 12 month period. LPA provided a copy of LIC 9224 and fact sheet to Director.

A Notice of Site Visit has been issued and must be posted for 30 days.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/29/2021 08:10 AM - It Cannot Be Edited


Created By: Samantha Yip On 06/28/2021 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ONE WORLD
FACILITY NUMBER: 434416683

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
06/29/2021
Section Cited
CCR
101170(d)

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Criminal Record Clearance. All individuals subject to criminal record review shall, be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
This requirement was not met as evident by:
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By POC 06/29/2021, Licensee stated that she will have S-1 and S-2 get re-fingerprinted.

Licensee sent both staff home.
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Based on record review, LPA observed that S-1 and S-2 was present at the facilty during today's inspection, but their fingerprints were not cleared. This poses an immediate risk to the health and safety of the 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 Studebaker
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2021


LIC809 (FAS) - (06/04)
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