434416686-8-25-2021-07-CC-SYIP-C68UZQ-20210825160151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416686
Report Date: 08/25/2021
Date Signed: 08/25/2021 04:01:55 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:	MEDINA, MACYET		FACILITY NUMBER:	434416686
ADMINISTRATOR:	MACYET MEDINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 912-5163
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	14	CENSUS: 4	DATE:	08/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Macyet Medina		TIME COMPLETED:	04:05 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 unannounced Required- 1 Year inspection. LPA met with Licensee Macyet Medina and explained the reason for the inspection. Present during today's inspection were Licensee, one daycare children, and three of her own children, whom two were infant age. Her spouse arrived shortly after. There is a board to posted required postings. The hours of the operations are Monday through Friday 630AM to 5:30PM. There is working phone in the home. LPA toured in the inside and outside of the home. The off-limit areas of the home are the living room, kitchen, the bedroom downstairs, garage, the entire upstairs, the backyard, and the left side of the backyard. LPA reminded Licensee to ensure that any off-limits are barricaded. There are stairs in the home, which as a gate. LPA reminded Licensee to ensure that stairs are barricaded at all times. The home was observed to be clean. All furniture and equipment were observed to be good conditions. LPA discussed with Licensee about the safe sleep regulations and the requirement to document that she is checking infants every 15 minutes. There were no baby walkers observed during today's inspection. All cleaning supplies, disinfectants, and other items that could pose a risk to children were inaccessible. LPA reminded Licensee that any hand sanitizer or anything that states to keep out of reach of children needs to be inaccessible to children. There is fully charged fire extinguisher, smoke detector, and carbon monoxide. Licensee stated that there are no weapons, such as firearms, stored in the home. The last fire/disaster drill was conducted on 06/23/2021. ---------------------CONTINUES ON 809 DATED 08/25/2021 PAGE 2---------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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: MEDINA, MACYET	FACILITY NUMBER: 434416686
	VISIT DATE: 08/25/2021

NARRATIVE

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-----------------CONTINUATION OF 809 DATED 08/25/2021 PAGE 1-----------------------------

Licensee only uses the right side of the yard. All play structures and toys were observed to be in good condition. LPA reminded Licensee to ensure that she is checking for any cobwebs and cleaning it. There is a pool in the backyard, which has the required fencing. There were no other bodies of water observed during today's inspection.

Licensee stated that she does not transport children, but understands that children cannot be left alone and unattended in parked vehicles. Licensee also stated that she is not providing Incidental Medical Services (IMS).

A copy of the facility roster was obtained. One child's file were reviewed during today's inspection. The records reviewed include but not limited to Emergency Contact Card.

Licensee has a valid CPR/1st Aid, which expires on 06/2022. Licensee has completed the Mandated Reporter training on 01/12/2020. LPA reminded Licensee that the Mandated Reporter Training requires renewal every two years. Licensee's immunization records for measles and pertussis are on file.

The adults living in the home are Licensee and her spouse. All adults have cleared criminal records, child abuse index, and TB test results. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, 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.

In the areas evaluated during today's inspection, no deficiencies have been cited. An exit interview was conducted where this report was discussed and provided to Licensee Macyet Medina. A Notice of Site Visit has been issued and must be posted for 30 consecutive days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC809 (FAS) - (06/04)

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