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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444416383
Report Date: 08/28/2019
Date Signed: 08/28/2019 10:32:50 AM

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:MARTINEZ, JESSICAFACILITY NUMBER:
444416383
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
08/28/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Jessica MartinezTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) met with Jessica, Applicant today for pre-licensing inspection. Current residents in this home are the applicant, her husband, her mom and dad, grandmother, aunt, her adult daughter, and applicant's minor child and her minor brother and sister. All adults living in the home obtained criminal record and TB test clearance on file. The home is leased by the applicant; LPA reviewed control of property. The off limit areas inside the home are 4 bedrooms and kitchen, The off limit areas outside are detached garage, laundry room, studio apartment, storage room and little area that is separated from the yard by mush fence. Prior to utilizing any off limit areas, LPA shall provide approval.
The home is heated, ventilated properly. The home is equipped with a fully charged, wrong size fire extinguisher, a working smoke detector. Applicant uses her cell phone for day care. The home meets the required posting area. All toxins are inaccessible to children. The home is free of hazardous materials. Applicant states there are no weapons in the home. Outside area is fully fenced. CPR and First Aid expires on 05/22/2021. Applicant has completed the 8 hours Preventive Health and Safety Training.
LPAs reminded applicant that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care homes. Applicant will use redirection and time-out as forms of discipline. Applicant understands that children's personal rights should not be violated, no corporal punishment is allowed.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2019
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: MARTINEZ, JESSICA
FACILITY NUMBER: 444416383
VISIT DATE: 08/28/2019
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Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements to hire assistant/substitute and the new car seat law and healthy beverages in child Care were discussed. Applicants understands food provided from home shall be labeled, emergency disaster [(Fire evacuation and Earthquake) drills must be conducted and logged at least once every six months], if liability insurance is not maintained at any time, the Affidavit of Liability Insurance form (LIC 282) shall be provided to parents. If providing care for two additional school age children, the form (LIC 9150) shall be provided to parents.
A Family Child Care Home packet was provided to and reviewed with the applicant. LPA also reminded applicant of the applicable $100 civil penalty per person per day, a maximum of $500 per person for those adults who have not received fingerprint clearances, are not associated to the license who come in contact with or provide care and supervision to the children. LPA discussed the requirements of AB 633 with the applicant and provided her a copy of acknowledgement of receipt of licensing reports (LIC 9224)
Incidental Medical Services (IMS) policy was discussed. She agreed to submit Plan of Operation if she decides to provide IMS services. Effect of lead exposure poster was provided to licensee and for their information and to share with children. Discussed also was safe sleep.

Prior to licensure applicant must:


1. Purchase size 2A10BC Fire extinguisher
2- Install Carbon Monoxide detector
The above most be corrected no later than 09/04/19.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2019
LIC809 (FAS) - (06/04)
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