434416686-8-6-2020-07-CC-SYIP-BS8MES-20200806093314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416686
Report Date: 08/05/2020
Date Signed: 08/06/2020 09:33:22 AM

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:	MEDINA, MACYET		FACILITY NUMBER:	434416686
ADMINISTRATOR:	MACYET MEDINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 861-8342
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	14	CENSUS: 1	DATE:	08/05/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Macyet Medina		TIME COMPLETED:	02:53 PM

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	Licensing Program Analyst (LPA) Samantha Yip conducted an announced pre-licensing inspection. Due to COVID-19 and shelter in place, a tele-inspection was conducted via Zoom. LPA met with Applicant Macyet Medina and explained the reason for the inspection. The purpose of this inspection is Applicant is changing location. Applicant is currently licensed at 3151 Peanut Brittle Drive, San Jose 95148 (#434415855). The hours of operation are Monday through Friday 6AM to 6PM. Licensee will using her cell-phone, but does have landline. Applicant does own the home and will send control property. Applicant also stated that she does have daycare insurance. Present during the inspection were Applicant, her spouse, her sister, and her minor child. There were no daycare children present during today's inspection. Applicant has a board for required postings, such as license, parent's right, emergency disaster plan, and earthquake preparedness. LPA inspected the inside and outside of the home via video call. A fire clearance was granted on 07/31/2020 for a capacity of 14. The off-limit areas of the home are the entire upstairs, kitchen, living room, laundry room, bedroom on the first floor, the garage, the backyard and the left side of the backyard. There are stairs in the home, which are barricaded. There is fireplace in the off-limit area of the home. All disinfectants, cleaning supplies, and other items that are dangerous to children were stored inaccessible to children. There is sufficient amount of toys for children. Furniture and equipment, such as table, chairs, napping mats, and play yard, were observed to be age appropriate. LPA discussed with Applicant about Safe Sleep. There were no baby walkers in the home. Applicant stated that there is no weapons, such as firearms, stored in the home. LPA reminded Applicant that any weapons and ammunition needs to be stored separately. Applicant stated that they have a safe in the master bedroom and in the garage. There is fully charged size 2 fire extinguisher, functioning smoke and carbon monoxide detector. LPA reminded Applicant that fire/disaster drill need to be conducted every 6 months and documented. ------------------------CONTINUES ON 809 DATED 08/05/2020 PAGE 2--------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020

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: MEDINA, MACYET	FACILITY NUMBER: 434416686
	VISIT DATE: 08/05/2020

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

-------------------CONTINUATION OF 809 DATED 08/05/2020 PAGE 1---------------------------
Applicant will only be using the right side of the backyard. The backyard is fenced. There is a pool in the backyard, which is in the off-limit area. The pool has at least a 5 feet high fenced and is self-latching. There were no other bodies of water. There is sufficient amount of toys and equipment for the children.

LPA emailed Applicant the Family Child Care Home packet with updated Licensing forms on 08/01/2020. Department website: www. ccld.ca.gov was provided to the Applicant. LPA reminded Applicant that Lead Exposure pamphlet needs to be given to any newly enrolled families.

Applicant stated that she will not transporting, but understands that children cannot be left alone and unattended in parked vehicles. Applicant also stated that she will not be providing Incidental Medical Services (IMS).

Applicant's immunization record for measles, pertussis, and influenza are on file. Applicant completed Mandated Reporter training on 01/12/2020. LPA reminded Applicant that Mandated Reporter Training requires renewal every two years. Applicant's CPR/1st Aid expires on 06/20/2022. Applicant has completed the Preventive Health, Safety, and Nutrition course and is in the process of completing training on lead prevention. Applicant stated that she will send proof of completion.

The adults who are living in the home are herself and her spouse. Applicant also has three minor children. All adults living in the home have cleared criminal record, child abuse index clearance, and TB test. LPA informed Applicant of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

LPA conducted an exit interview with Applicant. The 809 report dated 08/05/2020 will be emailed to Applicant. Applicant stated that she will confirm receipt of email within 24 hours. LPA advised Applicant upon approval of Licensing Management, a license for a Large Family Child Care Home will be granted and issued to Applicant upon completion of the following items:
1. proof of completion of lead prevention training

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2