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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444409098
Report Date: 06/26/2024
Date Signed: 06/26/2024 03:02:53 PM

Document Has Been Signed on 06/26/2024 03:02 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GUZMAN, MIZAIDAFACILITY NUMBER:
444409098
ADMINISTRATOR/
DIRECTOR:		MIZAIDA GUZMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 423-3826
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
06/26/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Mizaida GuzmanTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teodoro Trujillo conducted 3 year required inspection. LPA met with Licensee, Mizaida Guzman and informed her of the reason for today's inspection. Also present was adult daughter Vanessa, and adult nephew Jeffrey and three (3) day care children: two infant and one preschool age. The hours of operation are Monday - Thursday, 8:30 AM - 4:30 PM and Friday 9:00 AM to 4:00 PM. Licensee and her husband, daughter Vanessa and nephew Jeffrey are the only adults living in the home.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 06/24/2024 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have not received criminal record and child abuse index clearances or exemptions. Licensee's daughter Vanessa and nephew Jeffrey who lives in the converted tool shed have not obtained criminal background checks. Licensee states Jeffrey has been present since 12/2022. Licensee Mizaida was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.



LPA inspected the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the children in care. LPA observed construction tools by fence area in the back yard children play area that need to be removed or barricaded. LPA observed children back yard area toys that have been chewed with frayed corners making them unsafe for children in care.

Off limit areas in the home are as follows: attached studio, bedrooms 1, 2, 3 and hall way bathroom by bedroom 1, dining room and kitchen. Licensee has a gate to prevent children from accessing the kitchen area that does not latch. Licensee needs to update facility/yard sketch. LPA reviewed 3 children files; all 3 files are missing the Affidavit Regarding Liability Insurance (LIC 282) in their files. LPA observed storage shed has been converted for living quarters with outside bathroom. Backyard is fenced all around- left and right side yards are off limits and fenced off to prevent children from accessing those off limit areas.

Continues report dated 06/26/2024 pg. 1/3

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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 14
Document Has Been Signed on 06/26/2024 03:02 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/26/2024 at 12:23 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: GUZMAN, MIZAIDA
FACILITY NUMBER: 444409098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in, On-limit bathroom had facial cleaning products under bathroom sink cabinet and shampoo in bathtub, bedroom 1 and 2 door were open during site visit with multiple beauty products on top of bedroom cabinets which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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Licensee closed bedroom doors and removed items under bathroom sink during site visit. Licensee will submit a written statement of her understanding of CCR 102417(g)(4) and preventive measures by close of business 06/27/24.
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in licensee daughter Vanessa and nephew Jeffrey have not obtained criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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Licensee will send proof of criminal record clearance for daughter Vanessa and Jeffrey to the San Jose Regional Office by close of business 06/27/24. In addition, adult resident Jeffrey shall not be present until a criminal background clearance has been obtained.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/26/2024 03:02 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/26/2024 at 12:23 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: GUZMAN, MIZAIDA
FACILITY NUMBER: 444409098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in, back yard play area has construction tools in play area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Licensee will barricade or remove tools and submit photos of play area by close of business 07/10/24.
Type B
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in children toys in back yard area have corners that have been chewed by licensee pet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Licensee will remove and replace children outside toys that have been destroyed and will submit proof of purchase/replacement to the San Jose Regional Office by close of business 07/10/24.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 06/26/2024 03:02 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/26/2024 at 12:23 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: GUZMAN, MIZAIDA
FACILITY NUMBER: 444409098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation, interview, and record review, the licensee did not comply with the section cited above in Child 2 and Child 3 do not have safe sleep log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Licensee shall immediately start safe sleep logs and will submit proof of safe sleep logs for all infants in care by close of business 07/10/24.
Type B
Section Cited
CCR
102416.2(a)(2)
Reporting Requirements
(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (2) Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in licensee daughter Vanessa and nephew Jeffrey have not been added to the application which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Licensee will submit an updated LIC 279 Application by close of business 06/28/24.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 06/26/2024 03:02 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/26/2024 at 12:23 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: GUZMAN, MIZAIDA
FACILITY NUMBER: 444409098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in all children files do not have LIC 282 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Licensee will send copies of completed LIC 282 to the San Jose Regional Office by close of business 07/10/24.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in Child 2 and child 3 do not have 15 safe sleep log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Licensee will send copies of safe sleep logs for all enrolled infants in care to the San Jose Regional Office by close of business 07/10/24
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:Susy Cervantes
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


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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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GUZMAN, MIZAIDA
FACILITY NUMBER: 444409098
VISIT DATE: 06/26/2024
NARRATIVE
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Continuation of report dated 06/26/2024 pg. 2/3

LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, and no bodies of water. The Licensee states that she does not have weapons in the home. All detergents, cleaning compounds, poisons, medications, and other similar items accessible to children. On limit bathroom had facial cleaning products under bathroom sink cabinet, bedroom 1 and 2 door were open during site visit with multiple beauty products on top of bedroom cabinets.

LPA observed a current roster of the children that needs to be updated with children that have left. LPA observed a fire and disaster drill log last performed on 04/12/24. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was discussed. LPA observed licensee completed Mandated Reporter Training on 04/22/24. Licensee has Pediatric CPR/1st Aid expiring on 01/26/27. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is current for licensee, and all adults residing in the home.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS currently. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

LPA discussed the safe sleep regulations with licensee Mizaida and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee Mizaida 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. Licensee states infants in care do not have sleep logs.



To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Continues report dated 06/26/2024 pg. 2/3
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GUZMAN, MIZAIDA
FACILITY NUMBER: 444409098
VISIT DATE: 06/26/2024
NARRATIVE
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Continuation of report dated 06/26/2024 pg. 3/3
Licensee Mizaida Guzman was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee Mizaida Guzman, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS

Type A and Type B Deficiencies were cited today. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Type A deficiencies were cited during today's visit. LPA Teodoro Trujillo informed licensee Mizaida Guzman that this report dated 06/26/24 document(s) 2 (two) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA Teodoro Trujillo informed the licensee Mizaida Guzman to provide a copy of this licensing report dated 06/26/24 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the licensee Mizaida Guzman.

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.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
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