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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274416912
Report Date: 05/08/2025
Date Signed: 05/08/2025 01:00:16 PM

Document Has Been Signed on 05/08/2025 01:00 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:TAPIA GUTIERREZ, YUSDIVIAFACILITY NUMBER:
274416912
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
05/08/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:36 AM
MET WITH:Yusdivia TapiaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Elizabeth Larios, met with Applicant, Yusdivia Tapia for announced pre-licensing inspection. The purpose of today's inspection is to ensure the home is in compliance with Title 22 California Code of Regulations. Upon arrival, LPA was admitted into the home by the Applicant and toured inside and outside during todays inspection.

The Applicant states there are additional adults, over the age of 18, residing in the home. The Applicant has three minor children that reside in the home. LPA advised that children living in the home will be included in the home ratio and capacity until they turn 10 years of age. The hours of operation for the family child care home (FCCH) will be Monday - Saturday, 6:00AM-6:00PM the Applicant is planning to offer care for children ages 6 months to 12 years old. The Applicant has submitted Property Owner/Landlord Consent Family Child Care Home and does not currently have liability insurance for the day care. LPA advised the Applicant to provide parents with Affidavit Regarding Liability Insurance (LIC 282) upon registration until liability insurance is purchased in the future.

The 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.

LPA toured inside the home and ob11served sufficient materials and play equipment for day care children. There are blocks, puzzles, arts and craft materials, and other toys for children to play with. Off limits inside the home include: master bedroom/bathroom, and bedroom #1, 3, and 4. Off limits outside: entire backyard including the left and right side, and front yard. There is a working telephone (cell phone) at the FCCH. The b bn ,bn .bnApplicant has a 6 cots with sheets for children to nap. Applicant also does not have a crib or play yard. LPA advised that mattress sheets should be changed between infants, if the crib or play yard is shared. LPA advised that infant sheets shall be washed daily.

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Larios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: TAPIA GUTIERREZ, YUSDIVIA
FACILITY NUMBER: 274416912
VISIT DATE: 05/08/2025
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Food, snacks, and drinks will be prepared by Applicant. The Applicant states she is interested to work with a food program, and subsidized payment program (MAOF). Water will be provided for children from bottled water served in plastic cups. LPA observed cleaning compounds and kitchen knives properly stored inaccessible to children. The cabinets in the kitchen are properly locked and the fridge for storing children's food is properly maintained. The Applicant states there are no firearms in the home.

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: http://www.ada.gov/childqanda.htm.The Applicant states she will not offer Incidental Medical Services.

The bathroom in the home is clean, sanitary, and operable. The Applicant did not have a diaper changing station or pad. Applicant plans to assist with potty training and has a potty training seat. There is a waste bin with a tight fitting lid in bathroom.

LPA toured outside the home and observed the front backyard and backyard is fenced. No outdoor bodies of water were observed during todays inspection. Applicant states the entire backyard & front yard is off limits until further notice.

LPA observed fully charged 3A40BC fire extinguisher in the kitchen area, functioning smoke detectors and carbon monoxide detector. LPA advised completing annual maintenance for the fire extinguisher. The Applicant was provided fire/emergency disaster drill log and was advised drills should be completed every 6 months.

The Applicant state that for discipline of the children, she will talk verbally with the child and use redirection as needed. LPA advised that if utilized, the recommended duration for "time out" is 1 minute per year of age for the child. The Applicant understands that children's personal rights should not be violated; including no corporal punishment. Children should not be left for extended periods of time in furniture such as a high chair or play pen.
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Larios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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: TAPIA GUTIERREZ, YUSDIVIA
FACILITY NUMBER: 274416912
VISIT DATE: 05/08/2025
NARRATIVE
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LPA discussed isolation of sick children with the Applicant and state that if a child were to start feeling sick at her home that she would isolate the child in the entry area with a napping cot/mat, until the parent/guardian arrives to pick-up. LPA discussed isolation strategies, such as using a baby gate, and utilizing the restroom if the child's symptoms need close restroom access. Applicant has a first-aid kit and needs a thermometer.

LPA additionally discussed supervision of children, unusual incidents (LIC 624B), and requirements for additional staff/ adults living in the home. The Applicant states she does not plan to transport children at this time. The Applicant understands she must be home at least 80% of the time FCCH is open.

LPA reviewed small family child care home capacity requirements with the Applicant and provided copy of 102416.5 Staffing Ratio and Capacity from California Code of Regulations. The Applicant understands the requirements of one child in kindergarten or elementary school and at least one child age six for capacity of eight (complete LIC 9150). There should never be more than four infants present at the FCCH. LPA advised the Applicant that infants are children under 2 years of age.

LPA reviewed with the Applicant LIC 311D- Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant. LPA discussed required postings with Applicant and provided copies of Parents Rights bulletin (PUB 394) and Earthquake Preparedness Checklist (LIC 9148). LPA discussed Provider Information Notices (PINs). LPA additionally reviewed CCLD website and online annual fee payment.

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.

LPA discussed the safe sleep regulations with the Applicant and provided 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.

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Larios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: TAPIA GUTIERREZ, YUSDIVIA
FACILITY NUMBER: 274416912
VISIT DATE: 05/08/2025
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The Applicant were 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.

Exit interview conducted and report was reviewed with the Applicant, Yusdivia Gutierrez Tapia.

LPA advised the Applicant that a small FCCH license will be issued pending the items below.

-Water fountain
-Crib or play yard
-Thermometer & scissors
-Diaper changing table
-Diaper changing pad
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Larios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC809 (FAS) - (06/04)
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