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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270766755
Report Date: 05/28/2024
Date Signed: 05/28/2024 11:55:11 AM

Document Has Been Signed on 05/28/2024 11:55 AM - 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:BANUELOS, BELENFACILITY NUMBER:
270766755
ADMINISTRATOR/
DIRECTOR:		BANUELOS, BELENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
8316753929
CITY:GONZALESSTATE: CAZIP CODE:
93926
CAPACITY: 12TOTAL ENROLLED CHILDREN: 7CENSUS: 6DATE:
05/28/2024
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Belen BanuelosTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Jimenez-Villanueva met with licensee Belen Banuelos for an unannounced Inspection on May 28, 2024, at 9:30am. LPA explained the nature of today’s inspection to her. Present during today’s visit was the licensee with six preschoolers. Days and hours of operation are Monday to Friday from 7:00am to 5:00pm. Adults living in the home are the licensee and Licensee’s husband.

A review of staff records on 05/21/2024 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Belen Banuelos 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 toured the indoor and outdoor areas of the home during today’s inspection. LPA observed a covered fireplace, no stairs, and no bodies of water. Licensee stated there are no weapons. LPA observed a cat and dog, licensee states the dog stay inside the house and the cat outside in the yard, licensee states both are vaccinated. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children and stored top kitchen cabinet and in the laundry room. LPA observed a Carbon monoxide and smoke detector were operable. LPA observed a fully charged 3A10BC fire extinguisher, that was serviced on 10/4/2023. Side yard is fenced. Off limit areas: four bedrooms, one bathroom, garage, and backyard that is fenced off.

Continues on page 2.

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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 5
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: BANUELOS, BELEN
FACILITY NUMBER: 270766755
VISIT DATE: 05/28/2024
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Continues from page 1.

LPA observed licensee has a current CPR and First Aid certification dated 08/20/2023 expiring 08/20/2025 and completed Mandated Reporter training on 03/19/2024 and expires 03/19/2026.

LPAs took a picture of a current roster of the children and a fire and disaster drill log which was last completed on 05/28/2024. LPA reviewed six children files and observed Children (1 to 6) missing PM 286, Child (2) missing a complete LIC 627 and Child (6) missing Immunization card all other forms are completed in every file. LPA observed LIC 282 on files. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee.


Supervision of children was discussed with 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 options and she understand that she cannot have more than 12 children in the home at any time. License does not have an assistant and she is operating as a Small Family Child Care Home. Licensee stated she does not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.

LPA discussed the safe sleep regulations with licensee Belen Banuelos 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 Belen Banuelos 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.

Continues on page 3.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
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: BANUELOS, BELEN
FACILITY NUMBER: 270766755
VISIT DATE: 05/28/2024
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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

Licensee 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.

Exit interview conducted and report was reviewed with the licensee Belen Banuelos


During the exit interview, the LICENSEE Belen Banuelos, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The following type B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiency by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

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: Belinda Devall
LICENSING EVALUATOR NAME: Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/28/2024 11:55 AM - It Cannot Be Edited


Created By: Martha Jimenez-Villanueva On 05/28/2024 at 11:11 AM
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: BANUELOS, BELEN
FACILITY NUMBER: 270766755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 in LPA observed Child (6) missing Immunization card which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
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Licensee will submitt proof of complete Immunization Report for Child (6) to SJRO to the end of business day 06/22/2024.
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

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 in LPA reviewed six children files and observed Children (1 to 6) missing PM 286, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
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Licensee will submitt proof of complete PM 286 for six children to SJRO to the end of business day 06/22/2024.
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:Belinda Devall
LICENSING EVALUATOR NAME:Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/28/2024 11:55 AM - It Cannot Be Edited


Created By: Martha Jimenez-Villanueva On 05/28/2024 at 11:11 AM
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: BANUELOS, BELEN
FACILITY NUMBER: 270766755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

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 in LPA observed and reviewed Child (2) missing a complete LIC 627 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
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Licensee will submitt proof of complete LIC 627 for Child (2) to SJRO to the end of business day 06/22/2024.
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:Belinda Devall
LICENSING EVALUATOR NAME:Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024


LIC809 (FAS) - (06/04)
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