<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274416758
Report Date: 02/25/2022
Date Signed: 02/25/2022 12:11:32 PM

Document Has Been Signed on 02/25/2022 12:11 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:FABIAN ELIZALDE, MARIAFACILITY NUMBER:
274416758
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
02/25/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria Fabian ElizaldeTIME COMPLETED:
12:10 PM
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
Licensing Program Analyst (LPA) Elizabeth Larios conducted an announced pre-licensing inspection today. LPA arrived at the home and met with Maria Fabian Elizalde, Applicant. The purpose of today's pre-licensing inspection: address the Application for a Small Family Child Care Home license that the Applicant submitted to the Department on December 22, 2021.

Application/Record Review: The Applicant was the only adult present in the home during today's inspection. The Applicant, Applicant's spouse (Rodolfo Pompa Merlos), Applicant's brother (Oscar Fabian),are the adults residing in the home. The Applicant also has two minor siblings ages 17, and 14 who reside in the home. Days and hours of operation will be Monday to Friday from 5:00 AM to 6:00 PM and Saturday 5:00AM to 1:00PM. The Applicant has completed the Preventative Health and Safety Child Care Training (copy of certification on file). The Applicant has current CPR and First Aid certifications on file (exp: 06/19/2023). Current vaccinations (including flu vaccine opt out) and proof of completion of the Mandated Reporter Training for Child Care Workers (exp: 11/29/2023) are on file. The Applicant rents the home and The Property Owner/Landlord Notification form (LIC 9151) is on file and the Applicant understands that she cannot care for more than six children without the Property Owner/Landlord Consent form (LIC 9149) on file. All individuals subject to a criminal record review (Applicant, Applicant's spouse, and Applicant's brother have obtained a criminal record and child abuse index clearances prior to today's inspection.

Physical Plant tour: LPA toured the indoor & outdoor areas of the home with the Applicant during today's inspection. There is a working telephone in the home (cell #(831)205-9625). The home is clean and orderly, with central heating/air conditioning, and ventilation for safety & comfort. There are no stairs inside the home. There are no wall heaters inside the home. The off limit areas inside the home are: all bedrooms, one bathroom located in Master bedroom, and attached garage. Off limit areas outside the home are: none. The off limit areas inside the home are inaccessible to children. There are safe and age appropriate toys, play equipment, and materials for the children in the home.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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 3
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: FABIAN ELIZALDE, MARIA
FACILITY NUMBER: 274416758
VISIT DATE: 02/25/2022
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
26
27
28
29
30
31
32
Physical Plant tour (cont.): The Applicant has a designated area in the home (entryway) where a child(ren) can be isolated if exhibiting signs of illness. The home has working smoke/carbon monoxide detectors in the home. The Applicant has one fully charged fire extinguisher (3A40BC) inside the home. The Applicant does not have any firearms/ammunition or pets in the home. All cleaning compounds and medications are adequately stored (high cabinets) and inaccessible to children. There are no poisons inside the home The Applicant states that she does not have any baby walkers in the home. The Applicant understands that baby walkers are not allowed in the day care. LPA advised the Applicant that baby bouncers, jumpers, saucer chairs, and trampolines are allowed; however, she must follow manufacturer instructions re: use of such items. The Applicant understands that inclined sleepers are not allowed in the home. The Applicant understands that high chairs are to be used only for eating purposes. The Applicant states that she does not smoke and she understands that smoking is prohibited in the home. The Applicant has a first aid kit in the home with sufficient emergency supplies. The Applicant does have a touch less thermometer in the home.

Kitchen tour: The refrigerator and freezer in the home is clean. There are no sharp utensils, cleaning products, lighters/matches, or open bottles of alcohol accessible to children. The Applicant understands that any food/drink which is brought by parent(s) of day care child(ren) must be properly labeled with the child(ren) name and properly stored or refrigerated.

Bathroom tour: The bathroom toilet and faucet are clean, safe, and operable. The shower is free of any hazards. All shampoos, soap, medication, mouthwash, perfumes, razors, cleaning products, air fresheners, and nail polish/remover are inaccessible to the children.

Outdoor tour: The backyard area of the home is safe and secure for the children. The backyard area is adequately fenced and there are no bodies of water. LPA reminded the Applicant that the children must be supervised at all times while outdoors.

Document/Regulation Review: A Family Child Care Home packet with updated Licensing forms was provided/discussed with the Applicant during today's inspection. Documents from the packet, including but not limited to the following were discussed and reviewed with the Applicant: 1) Child Care Facility Roster (LIC 9140) must be complete and current at all times, 2) Fire/disaster drills must be practiced at least once every 6 months and documented on the fire/disaster drill log provided to the Applicant, 3) Posting requirements - Parent's Rights (PUB 394), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), and Facility License, 4) Staffing & Ratio - capacity/ratio limitations handout, 5) Safe Sleep Regulations, 6) Lead Flyer Requirement (PIN 20-01-CCP), 7) Forms and Records to keep in your Family Child Care Home (LIC 311D), & 8) COVID-19 required postings/resource/self-assessment information. COVID-19 self-assessment also completed during today's inspection.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: FABIAN ELIZALDE, MARIA
FACILITY NUMBER: 274416758
VISIT DATE: 02/25/2022
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
26
27
28
29
30
31
32
Forms of discipline used by Applicant: talking to children/time-out. The Applicant understands that children's personal rights should not be violated; including no corporal punishment, supervision of children, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed with the Applicant during today's inspection.

Incidental Medical Services (IMS) policy was discussed with the Applicant during today's inspection. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm. The Applicant states that she does not plan on administering medication at this time.

Notification requirements/civil penalty: LPA discussed the requirements of AB 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected. LPA reminded the Applicant of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

An exit interview was conducted with Applicant and was informed that upon approval of Licensing Management, a license for a Small Family Child Care Home will be granted and issued to Applicant.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3