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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444409824
Report Date: 09/27/2019
Date Signed: 10/01/2019 01:18:17 PM

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:ORTIZ, LETICIAFACILITY NUMBER:
444409824
ADMINISTRATOR:LETICIA ORTIZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 722-5094
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:14CENSUS: 3DATE:
09/27/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Leticia Oritz TIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Elizabeth Berumen conducted an unannounced annual random inspection. Present in the home were Licensee, 3 day care children (1 infant, 2 preschoolers) and assistant, Martha Zaragoza. Licensee, her husband, her three adult sons and daughter in law, Anna Zavala are the adults residing in the home.

The day-care is open Monday thru Friday from 6:00 AM to 6:00 PM. Licensee has current CPR and First Aid certification with an expiration date of August 29, 2020. The indoor and outdoor areas were inspected. The home is clean and orderly. Off limit areas in the home: kitchen, 3 bedroom, 1 barricaded fireplace (located in the living room), laundry room and attached garage. Three storage sheds in the backyard are locked and off limits.

The carbon monoxide detector and smoke detector were tested and proved to be functioning. The home is equipped with a 3A40BC fire extinguisher. LPA did not observe any bodies of water. Licensee states there are no weapons in the home. Cleaning supplies, medications, and sharp objects are stored inaccessible to children. LPA reviewed 11 children's files. LPA reviewed a current roster and reviewed fire disaster drill log.

Leticia completed the required Mandated Reporter Training. Assistant, Martha Zaragoza completed the Mandated Reporter Training on 09/09/19.
Martha Zaragoza has tuberculosis on file and is missing the immunization against pertussis, measles and influenza. Martha Zaragoza does not have fingerprint clearance association with the facility. Licensee states that Martha was fingerprinted on May 2, 2019. Licensee provided LPA with a copy of LIC 9163 Live scan service request and receipt dated May 2, 2019. LPA contacted CCL and provided clerical staff with Martha Zaragoza's information; she was not found on Licensing Information System (LIS).
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2019
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 3
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: ORTIZ, LETICIA
FACILITY NUMBER: 444409824
VISIT DATE: 09/27/2019
NARRATIVE
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LPA discussed Lead Safety Information (AB 2370). Chapter 676, statues of 2018, requires all child care providers, upon enrolling or re-enrolling any child, to provide the parent or guardian with written information. LPA provided Licensee with, Effects of Lead exposure flyer to handout to parents.

Safe Sleep was discussed: place infants on their backs when sleeping, use a firm sleep surface such as a mattress in a safety approved crib, keep soft bedding such as blankets, pillows, toys out baby's sleep area and ensure that pacifiers have nothing attached to them. LPA emailed Licensee link to access information.

LPA discussed with Licensee the violations that would result in an immediate assessment of civil penalty in the amount of $500. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online option to pay Annual License fee, etc.


Exit Interview was conducted. A copy of this report was provided to the Licensee at the conclusion of the inspection.

Deficiencies cited on 809 D

NOTICE OF SITE VISIT WAS ISSUED 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: 09/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: ORTIZ, LETICIA
FACILITY NUMBER: 444409824
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2019
Section Cited

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Crimainal Record Clearance
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.
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This requirement is not met as evidenced by: Based on LPA's inspection, interview, and review of records, Assistant, Martha Zaragoza is not associated with facility. Martha Zaragoza was fingerprinted on May 2, 2019 however, she is not associated to facility.
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Type B
10/11/2019
Section Cited

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A person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption. This requirement was not met as evidenced by:
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LPA reviewed Assistant, Martha Zaragoza's file and observed that she does not have Immunization against influenza, pertussis and measles. This poses a potential safety & health risk to children in care.
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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: 09/27/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2019
LIC809 (FAS) - (06/04)
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