<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444408356
Report Date: 05/02/2022
Date Signed: 05/04/2022 01:41:57 PM


Document Has Been Signed on 05/04/2022 01:41 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:PEREZ, SANDRAFACILITY NUMBER:
444408356
ADMINISTRATOR:PEREZ, SANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 722-5808
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:14CENSUS: 3DATE:
05/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Sandra PerezTIME COMPLETED:
01:50 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), Cortney Nelson, met with Licensee, Sandra Perez, for an unannounced Required- 1 Year Inspection. LPA was granted access to the home by the Licensee and toured both indoors and outdoors during the inspection. Upon arrival, there were 3 preschool aged children, Licensee, and Assistant, Bertha Romo, present, which is compliant with the home license capacity and ratio requirements. LPA observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Saturday, 6:00AM-6:00PM.

Licensee states that adults, over the age of 18, residing in the home are: herself, her spouse (Enrique Ornelas), her son (Enrique Ornelas-Perez), her daughters (Juliana Ornelas & Perla Ornelas), and renter (Cristian Barboso). All adults residing in the home have Criminal Background Check Clearance and signed Criminal Record Statements (LIC508).

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 reviewed facility roster (LIC9040) and fire/disaster drill log during todays inspection. The last fire/disaster drill was conducted on 4/5/2022, which is compliant with the six-month requirement for homes. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke detector and carbon monoxide detector. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. The Licensee states that there are no weapons or firearms in the home.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: PEREZ, SANDRA
FACILITY NUMBER: 444408356
VISIT DATE: 05/02/2022
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
26
27
28
29
30
31
32
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 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

Indoor areas of the home were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. Off-limits areas inside of the home: living room, kitchen, dining room, 3 bedrooms, 2 bathrooms, and attached garage. There is a rental unit in the backyard that is additionally off-limits. Licensee has a waiver for wood burning stove in the home and it is located in area off limits to children. Licensee understands that she cannot use the stove during day care hours. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. Drinking water is readily available for children in the facility via water dispensers and disposable cups. All food is provided to the children from the facility, day care home is enrolled into food program. The bathroom in the home is clean, sanitary, and operable. The Licensee has a working telephone (cellphone) in the facility. The facility has active liability insurance through KBK Insurance Agency expiring 5/1/2023.

The outside area of the home was inspected and LPA observed sufficient play-equipment and supplies for the children that are in good condition and age-appropriate. There is a functioning sink in the backyard for children to use. Off-limit areas outside of home include: left side yard and area outside of gated play area. No outdoor bodies of water were observed during todays inspection.

Licensee states that she does not currently have any infants in care. LPA discussed the safe sleep regulations with 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.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: PEREZ, SANDRA
FACILITY NUMBER: 444408356
VISIT DATE: 05/02/2022
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
26
27
28
29
30
31
32
3 children’s files were reviewed during todays inspection and all required documents were present.

Licensee, Assistant, and Home Resident files were reviewed and all required documents were present. LPA reminded Licensee that home residents are required to complete TB test and Criminal Record Statement (LIC508) in addition to fingerprint clearances. Licensee has current CPR/First-Aid that expires 3/19/2023 and current Mandated Reporter Training that expires on 6/25/2022. LPA reminded Licensee that Mandated Reporter and CPR/First-Aid must be renewed every 2 years.

Supervision of children was discussed with the Licensee and she understands that she must be home during day care hours and ensure that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Sandra Perez.

As a result of todays inspection, deficiencies were cited, see 809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/04/2022 01:41 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: PEREZ, SANDRA
FACILITY NUMBER: 444408356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)
(b) The applicant shall provide all of the folowing information at the time of submission of the application (9) Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in for 2 out of 5 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
1
2
3
4
Licensee will submit TB test results for all adults living in the home by 5/31/2022.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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 SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4