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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444406012
Report Date: 12/19/2023
Date Signed: 12/19/2023 04:53:15 PM

Document Has Been Signed on 12/19/2023 04:53 PM - 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:BETTENCOURT, NATALFACILITY NUMBER:
444406012
ADMINISTRATOR:BETTENCOURT, NATALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 722-1357
CITY:FREEDOMSTATE: CAZIP CODE:
95019
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
12/19/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Natal Bettencourt TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Larios met with Licensee Natal for an unannounced Required – 3 year annual inspection. LPA was granted access to the home by the Licensee. LPA observed three children in care during inspection. LPA observed the required postings, including the facility license, near the front entrance to the home. Days and hours of operation are Monday - Friday from 7:30 AM to 5:30 PM. Licensee and spouse & grandson are the only adults residing in the home.

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 9/19/ 2023. Licensee does have liability insurance for the day care (expiration 05/2024). Licensee has current CPR and First Aid certifications (expiration:01/15/2024). Licensee has the required vaccines (MMR, Tdap, & flu) and is current with the Mandated Reporter Training for Child Care Workers (expiration: 05/06/2024). LPA reviewed three children's files and the files were complete with the required forms. LPA reviewed one staff file (Licensee) and the file was complete with the required forms.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. The home is clean, orderly, (including heating/fans/ventilation), and safe for the day care children. There are safe & age appropriate toys, play equipment, and materials for the children in the home. There are no stairs inside the home. The off limit areas inside the home are: Master bedroom/bathroom, and bedroom one, and garage. Off limit areas outside (backyard) is the left and right side of the house, and storage.

LPA observed a fully charged fire extinguisher in kitchen area, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she does have pets in the home one dog and two cats and no weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Licensee states that she does not administer any medications to the day care children at this time.
Joel Segura
Elizabeth Larios
DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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: BETTENCOURT, NATAL
FACILITY NUMBER: 444406012
VISIT DATE: 12/19/2023
NARRATIVE
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Licensee states that she provides breakfast, lunch, and snacks to the day care children. Licensee states that she understands that any food brought from home needs to be labeled with each child's name and properly stored. Licensee has a first aid kit in the home. Licensee states that nobody smokes and she understands that smoking is prohibited in the home.

Incidental Medical Services (IMS) policy was discussed. 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

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity/ratio options and she understands that she cannot have more than fourteen children present in the home. Licensee states that a child will be isolated in the living room area if necessary due to illness or communicable disease. Licensee states that does not transport day care children. Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with the Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Exit interview conducted and report was reviewed with Licensee, Natal. Deficiencies were issued during today's inspection. A Notice of Site Visit must remain posted for 30 days.

SUPERVISOR'S NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/19/2023 04:53 PM - It Cannot Be Edited


Created By: Elizabeth Larios On 12/19/2023 at 04:08 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: BETTENCOURT, NATAL
FACILITY NUMBER: 444406012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Licensee did not comply with the section cited above. LPA observed infant (C1) with a teddy bear & small blanket in play yard which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2023
Plan of Correction
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Licensee immediately removed the teddy bear and small blanket from the infant (C1) inside the infant play yard. Licensee will review Infant Safe Sleep Regulations and submit a statement of understanding regarding ensuring cribs or play yards shall be free from loose articles at all times.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above two out of two infants did not have every 15 minutes check logs on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2023
Plan of Correction
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Licensee will submit every 15 minute checks for all infants in care.
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:Joel Segura
LICENSING EVALUATOR NAME:Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/19/2023 04:53 PM - It Cannot Be Edited


Created By: Elizabeth Larios On 12/19/2023 at 04:08 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: BETTENCOURT, NATAL
FACILITY NUMBER: 444406012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above child (C4) did not have immunization record on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2023
Plan of Correction
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Licensee will submit child (C4) immunization record.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above child (C4) did not have emergency information card which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2023
Plan of Correction
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Licensee will submit child (C4) emergency information record.
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:Joel Segura
LICENSING EVALUATOR NAME:Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
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