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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444406347
Report Date: 05/25/2022
Date Signed: 05/31/2022 01:02:16 PM


Document Has Been Signed on 05/31/2022 01:02 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:JIMENEZ, ROSALIAFACILITY NUMBER:
444406347
ADMINISTRATOR:JIMENEZ, ROSALIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 724-3429
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:14CENSUS: DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rosalia JimenezTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee, Rosalia Jimenez for an unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed 2 infants, 8 preschoolers and Licensee's assistant, Deli Martinez. Licensee states that her usual assistant is Valeria Montserrat Zaragoza who had an emergency appt. today and her back up Laura Catano had a family member pass away and notified Licensee on Thursday night. Deli Martinez was fingerprinted on May 23, 2022 and the status of her fingerprints are still pending.

Licensee was operating within her capacity and ratio requirements. LPA observed the required postings, including the facility license. Days and hours of operation are Monday - Friday from 6:00 AM to 6:00 PM. The adults residing in the home are: Licensee, tenants (Juan Garcia and Candelaria Torres, Joe Jimenez, Miguel Jimenez. and Licensee's 8 year old son.

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 April 28, 2022. Licensee states that she does have liability insurance for the day care. Licensee has current CPR and First Aid certifications. Licensee has the required vaccines (MMR, Tdap, & declines flu vaccine) and is current with her Mandated Reporter Training for Child Care Workers. LPA reviewed ten children's files. LPA reviewed two staff file (Licensee and two assistants).

LPA toured the on limit indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. The home is clean, orderly, and safe for the day care children. There are safe & age appropriate toys, play equipment, and materials for the children in the home. The tenants (Juan Garcia and Candelaria Torres) occupy a master bedroom, 2 bedrooms, bathroom in the downstairs portion of the home and have two minor children). Licensee states that she is currently not renting the garage which was previously rented to Lynn Torres. The entire upstairs is off limits to children. Upon LPA's arrival the stairs were not barricaded. Day care children have access to the living room (day-care room),bathroom and fenced backyard. The left side of the backyard is off limits to children. There are two storage sheds that are locked and off limits to children.

LPA observed a fully charged 3A40BC fire extinguisher, working smoke detector and no bodies of water. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Licensee understands that poisons are to be locked and inaccessible to the day care children. Licensee states that she does not have any weapons in home.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
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: JIMENEZ, ROSALIA
FACILITY NUMBER: 444406347
VISIT DATE: 05/25/2022
NARRATIVE
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Licensee states that she does currently does not administer any medications to the day care children. Licensee states that a child will be isolated in the living room area if necessary due to illness or communicable disease. 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 14 children present in the home with at least one qualified adult present at all times. Licensee states that does not transport day care children and she understands that children shall not be left unattended in parked vehicles. While reviewing children files LPA observed that Licensee has a transportation permission slip which she states is in care of an emergency. Licensee understands 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. Licensee is being accessed a civil penalty of $100.00 today for Deli Martinez not having criminal record clearances.

LPA discussed the safe sleep regulations with the Licensee and discussed the Child Care Licensing Safe Sleep webpage 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.

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 was conducted in Spanish and report was reviewed with the Licensee, Rosalia Jimenez. Deficiencies were issued during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/31/2022 01:02 PM - It Cannot Be Edited

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: JIMENEZ, ROSALIA
FACILITY NUMBER: 444406347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Carbon monoxide detector was not installed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2022
Plan of Correction
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Licensee had a new carbon monoxide/smoke detector which she installed during today's inspection. Deficiency is cleared today.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above Licensee's assistants' (Deli Martinez and Valeria M. Zaragoza) does not have current mandated reporter training; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Licensee agrees to submit copies of completed Mandated Reporter Training for both Deli and Adriana by plan of correction date of 06/01/22.

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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5


Document Has Been Signed on 05/31/2022 01:02 PM - It Cannot Be Edited

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: JIMENEZ, ROSALIA
FACILITY NUMBER: 444406347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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 infants (#2 and #10) do not have an Individual Sleeping Plan (LIC9227) completed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2022
Plan of Correction
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Licensee agrees to provide parents with the LIC 9227 to complete and Licensee will complete her portion of the LIC 9227. Licensee to submit copies to LPA Berumen by plan of correction date of 06/01/22.
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

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 infants (child #2 and #10) are missing the LIC 9227 in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2022
Plan of Correction
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Licensee agrees to file the completed LIC 9227 for child 2 and 10 and submit copies to LPA Berumen by plan of correction date of 06/01/22.

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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 05/31/2022 01:24 PM

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: JIMENEZ, ROSALIA
FACILITY NUMBER: 444406347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1023370(d)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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102370(d)(1) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement was not met as evidenced by:

Based on observation and record review the licensee did not comply with the section cited above Assistant, Deli Martinez does not have criminal record clearances which poses an immediate health and safety risk to persons in care. Licensee called her primary assistant who had an emergency appt to come to facility after so that Deli Martinez can go home. Li
POC Due Date: 05/25/2022
Plan of Correction
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Deli Martinez was fingerprinted on May 23, 2022 and status is still pending. Licensee to submit a written statement stating she understands that prior to adult working in the home he/she is to have criminal record clearances or association.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5