434416743-12-17-2021-07-CC-MSMS-C9SPZS-20211217104600

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416743
Report Date: 12/17/2021
Date Signed: 12/17/2021 10:46:11 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:	PACHECO, NEUSA		FACILITY NUMBER:	434416743
ADMINISTRATOR:	NEUSA, PACHECO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 518-2701
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	14	CENSUS: 0	DATE:	12/17/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Neusa Pacheco		TIME COMPLETED:	11:15 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	Licensing Program Analyst (LPA) Mel Matos conducted an announced prelicensing inspection today. LPA arrived at the home at 8:45 AM and met with Neusa Pacheco, Applicant. The purpose of today's prelicensing inspection: address the Application submitted for a large Family Child Care Home License. Applicant submitted her application to the Department on August 30, 2021. Letter verifying Applicant's experience working in a licensed child care is on file. Application/Record Review: Applicant was the only person present in the home during today's inspection. Applicant and her spouse are the adults residing in the home. Days and hours of operation will be Monday to Friday from 8:00 AM to 5:30 PM. Applicant is enrolled to take the Preventative Health and Safety Child Care Training in January 2022 since her class that was scheduled for December 2021 was rescheduled by the training provider. Applicant has current CPR and First Aid certifications on file (exp: 10/09/2023). Current vaccinations (including the flu vaccine) and proof of completion of the Mandated Reporter Training for Child Care Workers (exp: 10/20/2023) are on file. Applicant rents the home and a copy of the lease agreement verifying control of property is on file. The Property Owner/Landlord Notification (LIC 9151) and Property Owner/Landlord Consent (LIC 9149) forms are on file. Applicant states that she will obtain liability insurance for her day care once she is licensed. All individuals subject to a criminal record review (Applicant & spouse) have the required criminal record and child abuse index clearances on file. An approved fire safety inspection from the San Jose Fire Department was received on October 28, 2021. Physical Plant tour: LPA toured the indoor & outdoor areas of the home with the Applicant during today's inspection. There is a working telephone in the home (cell #650-518-2701). The home is clean and orderly, with central heating and ventilation for safety & comfort. There is one wall heater inside the home (located in the covered patio room) that is barricaded. There are no stairs inside the home. The off limit areas inside the home: Rooms 1, 2, 3, one bathroom, kitchen, barricaded fireplace unit, and attached garage. The off limit area outside the home: front yard and front left side area of the backyard. The off limit areas inside/outside the home are inaccessible to children. There are safe and age appropriate toys, play equipment, and materials for the children in the home.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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: PACHECO, NEUSA	FACILITY NUMBER: 434416743
	VISIT DATE: 12/17/2021

NARRATIVE

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Physical Plant tour (cont.): Applicant has a designated area in the home (living room) where a child(ren) can be isolated if exhibiting signs of illness. The home has working smoke/carbon monoxide detectors in the home. Applicant has one fully charged fire extinguisher (2A10BC) inside the home. Applicant states that she does not have any firearms/ammunition in the home. Applicant states that she does not have any pets in the home. All cleaning compounds and medications are adequately stored (high cabinets) and inaccessible to children. There are no poisons inside the home. Applicant states that she does not have any baby walkers in the home. Applicant understands that baby walkers are not allowed in the day care. LPA advised the Applicant that baby bouncers, jumpers, saucer chairs, and trampolines are allowed; however, she must follow manufacturer instructions re: use of such items. Applicant understands that inclined sleepers are not allowed in the home. Applicant understands that high chairs are to be used only for eating purposes. Applicant states that she does not smoke and she understands that smoking is prohibited in the home. The Applicant has a first aid kit in the home with sufficient emergency supplies. Applicant does have a touch less thermometer in the home.

Kitchen tour: The refrigerator and freezer in the home is clean. There are no sharp utensils, cleaning products, lighters/matches, or open bottles of alcohol accessible to children. Applicant understands that any food/drink which is brought by parent(s) of day care child(ren) must be properly labeled with the child(ren) name and properly stored or refrigerated.

Bathroom tour: The bathroom, including toilet and faucet, is clean, safe, and operable. The bathroom is free of any hazards. All shampoos, soap, medication, mouthwash, perfumes, razors, cleaning products, air fresheners, and nail polish/remover are inaccessible to the children.

Outdoor tour: The backyard area of the home is safe and secure for the children. The backyard area is adequately fenced and there are no bodies of water on the premises. LPA reminded the Applicant that the children must be supervised at all times while outdoors.

Document/Regulation Review: A Family Child Care Home packet with updated Licensing forms was provided/discussed with the Applicant during today's inspection. Documents from the packet, including but not limited to the following were discussed and reviewed with the Applicant: 1) Child Care Facility Roster (LIC 9140) must be complete and current at all times, 2) Fire/disaster drills must be practiced at least once every 6 months and documented on the fire/disaster drill log provided to the Applicant, 3) Posting requirements - Parent's Rights (PUB 394), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), and Facility License, 4) Staffing & Ratio - capacity/ratio limitations handout, 5) Safe Sleep Regulations, 6) Lead Flyer Requirement (PIN 20-01-CCP), 7) Forms and Records to keep in your Family Child Care Home (LIC 311D), & 8) COVID-19 required postings/resource/self-assessment information. COVID-19 self-assessment also completed during today's inspection.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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: PACHECO, NEUSA	FACILITY NUMBER: 434416743
	VISIT DATE: 12/17/2021

NARRATIVE

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Forms of discipline used by Applicant: talking to children. Applicant understands that children's personal rights should not be violated; including no corporal punishment, supervision of children, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed with the Applicant during today's inspection.

Incidental Medical Services (IMS) policy was discussed with the Applicant during today's inspection. 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. The Applicant states that she does not plan on administering medication at this time.

Notification requirements/civil penalty: LPA discussed the requirements of AB 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected. LPA reminded the 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 the Applicant and advised her that a "90 day provisional" large Family Child Care Home License is approved effective today, December 17, 2021. Applicant agreed to submit proof of completion of the Preventative Health/Safety course to LPA Matos upon completion of the course.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC809 (FAS) - (06/04)

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