444406227-12-21-2022-07-CC-EBEN-CMBTHG-20221221134443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444406227
Report Date: 12/15/2022
Date Signed: 12/21/2022 01:44:48 PM

Document Has Been Signed on 12/21/2022 01:44 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:	FERNANDEZ, ROSALIA		FACILITY NUMBER:	444406227
ADMINISTRATOR:	FERNANDEZ, ROSALIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 763-2095
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	14	CENSUS: 5	DATE:	12/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rosalia Fernandez		TIME COMPLETED:	03:30 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), Elizabeth Berumen met with Licensee, Rosalia Fernandez, for an unannounced Required - 1 Year Inspection. LPA observed 5 preschoolers and Licensee's assistant, Maria Socorro Delgado Ortiz. All required posted materials were posted in day care room area. The day-care is open Monday thru Friday from 6:00 AM to 6:00 PM. Licensee states there are 2 adults residing in the home: herself and her grandson Miguel Leon Fernandez. LPA observed a current children's roster (LIC9040). Fire/disaster drill was conducted on December 12, 2022. LPA observed a fully charged 2A10BC fire extinguisher, functioning smoke and carbon monoxide detectors, and barricaded fireplace in front living room area. Rosalia states that there are no weapons or firearms in the home. Incidental Medical Services (IMS) policy was discussed. Licensee states that she is not planning to administer any medication at this time. 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 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 LPA reminded licensee 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. Continuation on next page:

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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: FERNANDEZ, ROSALIA	FACILITY NUMBER: 444406227
	VISIT DATE: 12/15/2022

NARRATIVE

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Off limit areas inside the home are: two bedrooms, and attached garage. Off limit areas outside the home are detached shed in the backyard and right side of the backyard. The backyard is fenced.
Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (831)763-2095; Cell (831) 254-6088. Licensee has day care insurance acord, policy expires on 05/21/23.

LPA reviewed five children files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), Individual Infant Sleeping Plan (LIC 9227), and Immunization Records (PM 286/CDPH 286).

Rosalia's Mandated Reporter Training expires on January 2023. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years. Licensee has current Pediatric CPR/First Aid certifications with an expiration date of 01/30/23.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

Exit interview conducted and report was reviewed with Licensee, Rosalia Fernandez

As a result of today's inspection, there were no deficiencies cited.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC809 (FAS) - (06/04)

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