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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415340
Report Date: 03/04/2025
Date Signed: 03/04/2025 02:06:16 PM

Document Has Been Signed on 03/04/2025 02:06 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:AVILA, DORINAFACILITY NUMBER:
274415340
ADMINISTRATOR/
DIRECTOR:		AVILA, DORINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 229-8753
CITY:SOLEDADSTATE: CAZIP CODE:
93960
CAPACITY: 14TOTAL ENROLLED CHILDREN: 3CENSUS: 2DATE:
03/04/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Dorina AvilaTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Martha Jimenez-Villanueva met with licensee Dorina Avila for an unannounced annual/random inspection. LPA explained the nature of today’s inspection. Licensee was present and two (2) infants in care. All required posting materials were posted. Applicant stated: Days and hours of operation are Monday to Saturday from 6:00AM to 6:00 PM. Per licensee, the adults that reside in the home are herself and her husband and three sons. Licensee states no children living in the home. The day-care is a two story home with five (5) bedrooms and three (3) bathrooms.

A review of staff records on 03/03/2025 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 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.

Fire/disaster drill was conducted on February 19, 2025. LPA observed a fully charged 3A40BC fire extinguisher that was serviced on 02/25/2025, functioning at least a combo smoke and carbon monoxide detector. There are barricaded stairs, no bodies of water and no weapons/fire at home. LPA observed two pets at home, licensee stated pets are vaccinated and stayed outside. Licensee carries day-care insurance with Markel Insurance Company and its current.

LPA toured the indoor and outdoor areas of the home with the Licensee during today's inspection. Off limit areas in the home are all the second floor.LPA observed the home has a back yard and it is fenced. The home is clean, orderly, and has a central heat and air conditioning system for safe and comfort for the day care children. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible in a top cabinet in the kitchen area. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. The home has a working telephone (831-229-8753) in the home.
Report Continues LIC809C page 2.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AVILA, DORINA
FACILITY NUMBER: 274415340
VISIT DATE: 03/04/2025
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Report LIC 809C page 2.
LPA obtained a copy of current children's roster. LPA reviewed three (3) children's files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Immunization Record (CDPH 286), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Infant Sleep Log (LIC 9227), sleep log (for children 0-24 months), and Immunization Records. All required forms are on file exempting Child (1 and 3) missing Immunization Record (CDPH 286).

LPA reviewed licensee has current Pediatric CPR/First Aid certifications with an expiration date of March 25, 2025, licensee stated has scheduled renewal training on 03/15/2025. Licensee’s Mandated Reporter Training was completed on April 29, 2023. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

Supervision of children was discussed with the Licensee, and she understands that she must be present in the home during day care hours (80% of the operating hours) and ensure that the children are supervised at all times. Licensee understands her capacity/ratio options and she understand that she cannot have more than (14) children present in the home without at least one qualified adult present. Licensee states that a child will be isolated in a corner in the child care area if necessary due to illness or communicable disease. Licensee stated that she does not transports day care children. Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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-andresources/safe-sleep as an additional resource. PA also informed licensee 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.

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/.
Report Continues LIC 809C page 3.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
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: AVILA, DORINA
FACILITY NUMBER: 274415340
VISIT DATE: 03/04/2025
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Report LIC 809C page 3.

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.

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



The following type B deficiency was cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies 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.

Exit interview conducted and report was reviewed with the licensee Dorina Avila in Spanish.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/04/2025 02:06 PM - It Cannot Be Edited


Created By: Martha Jimenez-Villanueva On 03/04/2025 at 01:25 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: AVILA, DORINA
FACILITY NUMBER: 274415340

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 records reviewed, the licensee did not comply with the section cited above in CDPH 286 missing for Child (1 and 3) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Licensee will submit proof of current CDPH 286 for Child (1 and 3) to the CCLD by the end of 03/18/2025.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


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