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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274416700
Report Date: 12/11/2024
Date Signed: 12/11/2024 12:59:54 PM

Document Has Been Signed on 12/11/2024 12:59 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:SALAZAR, ROSAFACILITY NUMBER:
274416700
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 0DATE:
12/11/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rosa SalazarTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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On December 11, 2024, Licensing Program Analysts (LPA) Darnella Barnes and Fermin Campos-Jaramillo conducted an unannounced 3-year required inspection at the residence of Rosa Salazar, Licensee. LPAs observed that no children were present and in care today. Licensee was notified that the purpose of the inspection and the Entrance Checklist LIC126 was provided to the licensee.

The facility operates Monday to Friday from 6:00 a.m. to 5:00 p.m. Required postings, including the Facility License, PUB393 Notification of Parent's Rights, LIC6104 Emergency Disaster Plan, LIC9148 Earthquake Preparedness Checklist, and the emergency disaster drill log 11/4/2024 were visible in a publicly accessible area. The licensee was reminded to conduct fire and disaster drills every six months and document them accordingly.

The licensee stated that the only adults residing in the home are herself, her mother, and her sister. The licensee confirmed an understanding of capacity regulations. The licensee confirmed that she does not transport children and understands that children must not be left unattended in parked vehicles.

LPA verified safety items, including a fully charged 3A-40B-C fire extinguisher serviced on 5-31-24, operable smoke and carbon monoxide detectors, and a working telephone 831-728-9023 The licensee confirmed there are no firearms in the home.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Darnella Barnes
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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Document Has Been Signed on 12/11/2024 12:59 PM - It Cannot Be Edited


Created By: Darnella Barnes On 12/11/2024 at 11:35 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: SALAZAR, ROSA
FACILITY NUMBER: 274416700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above, licensee was unable to provide form LIC9227 for child number one, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2024
Plan of Correction
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Licensee shall complete form LIC9227 for child #1 and will send a copy to licensing program on or before December 26, 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:Susy Cervantes
LICENSING EVALUATOR NAME:Darnella Barnes
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


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: SALAZAR, ROSA
FACILITY NUMBER: 274416700
VISIT DATE: 12/11/2024
NARRATIVE
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A tour of the indoor and outdoor areas revealed that the home was clean, orderly, and equipped with ample age-appropriate materials for the children. The home also had appropriate heating and ventilation. Hazardous items, toxins, such as cleaning supplies and medications, were stored out of children's reach in inaccessible areas. LPA observed that Licensee has a portable room heater, and licensee stated she heats the room before the children arrives. There were no bodies of water or fireplaces present. Licensee stated that she has a small, vaccinated dog and she keeps in an off-limits area of the home.

The licensee has designated the indoor off-limits area is the second floor. LPA observed the off limits outside area include the driveway, patio, front yard and deck. These areas were made inaccessible to children with safety gates. LPA observed the child care is on the bottom floor of the home ..LPA discussed the safe sleep regulations with the licensee and provided information on 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 the licensee about 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 that they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA reviewed 5 children’s files all of which were complete, containing documentation of immunization, Parent's Rights acknowledgments, emergency information, consents for medical treatment, and affidavit liability insurance.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Darnella Barnes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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: SALAZAR, ROSA
FACILITY NUMBER: 274416700
VISIT DATE: 12/11/2024
NARRATIVE
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A review of staff records 12-03-24 showed that all adults residing in the home, as well as individuals requiring 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, 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.

The licensee provided proof of immunization for measles, pertussis, and influenza, as well as certificates for Preventive Health and Safety Training with the lead poisoning component, Pediatric CPR and First Aid 9/30/26, and Mandated Reporter training was completed 3/26/24.

Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 22-02CCP. 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 the link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Darnella Barnes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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: SALAZAR, ROSA
FACILITY NUMBER: 274416700
VISIT DATE: 12/11/2024
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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 site, 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 confirmed that there are no Registered Sex Offenders living in the facility, and LPA completed the RSO profile in FAS on 12/09/2024.

The exit interview was conducted, and the report was reviewed with the licensee.

One type B deficiency was cited today.

Failure to comply with the Plan Of Corrections (POC) by the due date on LIC809D shall result in an immediate civil penalty of $100 per day per each deficiency.

A notice of site visit was issued and must remain posted for 30 days.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Darnella Barnes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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