274416060-10-11-2022-07-CC-SCES-CK4PQ2-20221011113025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 274416060
Report Date: 10/11/2022
Date Signed: 10/11/2022 11:30:51 AM

Document Has Been Signed on 10/11/2022 11:30 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	LOPEZ, JAQUELINE		FACILITY NUMBER:	274416060
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	10/11/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Jaqueline Lopez		TIME COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/11/2022 at 10:05 AM, Licensing Program Analyst (LPA) Susy Cervantes met with applicant, Jaqueline Lopez, to conduct a pre-licensing visit. Applicant stated that the adults living in the home are licensee and their spouse with three children ages 1, 2, and 4. Applicant owns the house. Applicant plans to get liability insurance at this time and they understood that they will have parent/authorized representative sign the Affidavit Regarding Liability Insurance for FCCH form (LIC 282). A review of staff records on 10/11/2022 indicates that all staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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. The entire home was inspected for health and safety hazards. The home has a working smoke alarm and carbon monoxide detector, a working telephone and a 2A10BC fire extinguishers that was serviced on 10/10/22. Certifications for CPR and First Aid expire 01/2024. Preventative Health Practices training was completed on 02/26/22. Applicant has completed Mandated Reporter training on 01/26/22. Immunizations for Measles, Pertussis, and influenza are on file for applicant. Continues on report dated 10/11/2022 ______________________________ pg. 1/3

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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: LOPEZ, JAQUELINE	FACILITY NUMBER: 274416060
	VISIT DATE: 10/11/2022

NARRATIVE

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Continuation of report dated 10/11/2022 ______________________________ pg. 2/3

Applicant stated there are no weapons in the home and no pets. LPA observed no fireplace, no stairs and no bodies of water. Backyard is fenced. Off limit areas: three bedrooms, one bathroom, laundry room, garage right side yard and left side of the back yard that has been fenced off. The days and hours of operation will be Monday through Friday from 5:30 am to 6:00 pm. There were age appropriate toys in the child care areas. Bathroom was clean.

Cleaning products, hazardous and sharp objects were inaccessible to children and stored in the garage. Discipline policy was discussed with applicant and they understood that the children's personal rights should not be violated and corporal punishment is not allowed. Applicant stated that their discipline method will be talk to them. Applicant stated they will not transport children, they understood the safety seat belt/car seat requirements.

A Family Child Care Home packet was reviewed with applicant. Department's website: www.ccld.ca.gov to obtain forms and regulations CCR, Title 22 was provided. Applicants was advised on the regulations that smoking, baby walkers, bouncers, excersaucers and other similar items are not allowed. The following was discussed, isolation of sick children; supervision of children; capacity options; requirements for reporting suspected child abuse; unusual incident/injuries; fire drills practiced at least twice a year and documented. LPA also discussed the requirements of AB 633 to applicant and provided applicant the fact sheet and a copy of Acknowledgement of receipt of Licensing Reports (LIC 9224). Zero Tolerance deficiencies with $500 civil penalty was also explained to applicant. LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant 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.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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: LOPEZ, JAQUELINE	FACILITY NUMBER: 274416060
	VISIT DATE: 10/11/2022

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Continuation of report dated 10/11/2022 ______________________________ pg. 3/3

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the applicant, Jaqueline Lopez. LPA advised applicants that licensure for a small Family Child Care Home license is approved pending the following:

- Management's approval

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC809 (FAS) - (06/04)

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