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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415560
Report Date: 07/06/2021
Date Signed: 07/06/2021 03:38:28 PM

Document Has Been Signed on 07/06/2021 03:38 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MORALES, MARIAFACILITY NUMBER:
274415560
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
07/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maria MoralesTIME COMPLETED:
03:45 PM
NARRATIVE
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On 07/06/2021 at 02:30 PM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Maria Morales, for an annual inspection and explained the nature of today’s visit. Present during today’s visit were Licensee with 2 children (1 of which is their own): 2 preschool. Adults living in the home are licensee with three children ages 16, 16, and 8. Days and hours of operation are Monday through Saturday, 6:00 am to 6:00 pm.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 07/01/2021 was reviewed; and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100 per person per day, minimum of $100 to a maximum of $500 per person for an initial violation, and a minimum of $100 to a maximum of $3000 per person for any subsequent violation within a 12-month period.

LPA toured the inside and outside of the home. LPA observed no fireplace, a covered wall heater, and no stairs. Off limits indoor: two bedrooms and one bathroom. There are no bodies of water. Licensee stated there are two pets, a cat and dog, licensee showed proof of vaccination. Licensee stated there are no firearms/weapons. LPA observed a 3A40BC fire extinguisher that was fully charged. Smoke detector and Carbon Monoxide detectors are operable. Telephone is in working order. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored in the top kitchen cabinets. Backyard is fenced. Off limits outdoor: no off limit areas. LPA reminded licensee that she can only have 8 children according to their license. Children were supervised during the visit and LPA went over substitute options.

Continues on report dated 07/06/2021 pg. 1/2
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2021
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: MORALES, MARIA
FACILITY NUMBER: 274415560
VISIT DATE: 07/06/2021
NARRATIVE
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Licensee stated they do 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 took a picture of a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 03/10/2021. LPA reviewed one child’s file and observed a copy of the emergency information card (LIC 700) in each file. Infant individual sleeping plan (LIC 9227) for each infant under 12 months and a 15 minute check sleep log for infants under 24 months was discussed with Licensee. LPA observed that the Licensee has not completed Mandated Reporter training. Licensee has Pediatric CPR/1st Aid that has expired on 09/13/20. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee.

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 at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

Licensee was reminded that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice. LPA discussed the immediate civil penalties for Zero Tolerance of $500 and the Healthy Beverage Act and AB633 requirements for type A violation. Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA discussed the “Lead Poisoning Facts Information Flyer” to the facility. Department website: http://ccld.ca.gov provided to Licensee.

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.

An exit interview was conducted with Licensee in Spanish. Type B deficiencies were cited during today’s inspection
Notice of site visit must remain posted for 30 days.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2021 03:38 PM - It Cannot Be Edited


Created By: Susy Cervantes On 07/06/2021 at 03:15 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: MORALES, MARIA
FACILITY NUMBER: 274415560

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2021
Section Cited
HSC
1596.8662(b)(1)

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training... and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement was not met as evidenced by:
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Licensee will complete mandated reporter training at www.mandatedreporterca.com and submit certificate of completion to SJRO by 07/20/2021
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Based on record review, LPA did not observe a Mandated Reporter training certificate, licensee stated they had not completed the training.
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Type B
07/20/2021
Section Cited
CCR102416(c)

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102416(c) Personnel Requirement: The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement was not met as evidenced by:
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Licensee will enroll in a pediatric CPR and first aid course and send proof of enrollment to SJRO by 07/20/2021
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Based on record review, LPA observed an expired pediatric CPR and first aid.
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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 Segura
LICENSING EVALUATOR NAME:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2021


LIC809 (FAS) - (06/04)
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