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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274417517
Report Date: 07/28/2025
Date Signed: 07/28/2025 03:00:20 PM

Document Has Been Signed on 07/28/2025 03:00 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, RAFAELFACILITY NUMBER:
274417517
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
07/28/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:58 PM
MET WITH:Rafael TapiaTIME VISIT/
INSPECTION COMPLETED:
03:15 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
On July 28, 2025, Licensing Program Analyst (LPA) Darnella Barnes conducted an announced pre-licensing inspection at the applicant’s facility to ensure compliance with Title 22 of the California Code of Regulations. The purpose of the visit was explained, and access was granted by the applicant, Rafael Tapia. Present during the inspection were the applicant and his mother.

The applicant stated there are no additional adults over the age of 18 residing in the home. 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, 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.

In the applicant file, the Property Owner/Landlord Notification form (LIC 9151) is present, indicating it was provided to the property owner/landlord. A signed Property Owner/Landlord Consent form (LIC 9149) was also obtained.

Meals, snacks, and drinks will be prepared by the applicant. Operating hours will be Monday through Sunday, from 5:00 AM to 6:00 PM. The facility will provide care for children ages 0 months to 12 years. The LPA informed the applicant that children living in the home will be counted in the facility’s capacity until they turn 10 years old. The applicant acknowledged the requirement to supervise children at all times and confirmed understanding of the procedure for designating a qualified substitute during temporary absences, not to exceed 20% of operating hours. The LPA advised that if liability insurance is not maintained or the day care is not named on the policy, each child’s file must include a signed Affidavit Regarding Liability Insurance (LIC 282).

-----CONTINUED ON NEXT PAGES -----

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2025
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)
Page: 2 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, RAFAEL
FACILITY NUMBER: 274417517
VISIT DATE: 07/28/2025
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
LPA reviewed LIC 311D with the applicant, including required facility records, children’s records, and postings. An Entrance Checklist was provided.

LPA conducted a walk through of the home. The off-limits area includes one bedroom, applicant stated that the door to the bedroom will be closed during day care hours. The home was clean and orderly. Heating and ventilation systems were functional. Age-appropriate toys, play equipment, and learning materials were observed and free of hazards. The applicant understood the procedure for separating ill children. There is one wall heater in the living room that is screened that children have no access to. No visible hazards were present.

A fully charged 3A40ABC fire extinguisher purchased 7/27/25, a working smoke detector, a carbon monoxide detector, and a functional telephone were observed. The applicant was advised to complete annual maintenance on the fire extinguisher. A fire and emergency disaster drill log was provided. The applicant was advised to conduct and document drills every six months.

The applicant was reminded that if cribs or play yards are acquired for infants, each infant unable to climb out must have an individual unit. These must not obstruct entrances and exits, and be equipped with firm, fitted, and appropriately sized mattresses and sheets. No loose articles, bumper pads, or objects suspended above or attached to the sides are permitted.

Smoking is not permitted on the premises, and the applicant was reminded of this regulation. No baby walkers, bouncers, jumpers, or other prohibited items were observed. Hazardous materials, including cleaning compounds, detergents, medicines, and poisons, were stored in areas inaccessible to children. The applicant confirmed that there are no guns, ammunition, or firearms on the premises. No bodies of water were present.

The front yard will serve as the designated outdoor play area. It is enclosed by a fence at least five feet high. The left side of the home is designated as off-limits. The play yard included items such as toy trucks, balls, tent, and cars. Equipment was securely placed on AstroTurf and free of hazards. No bodies of water were observed. The applicant was reminded to notify licensing prior to making any changes to the home or yard.

-----CONTINUED ON NEXT PAGES -----

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
Page: 3 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, RAFAEL
FACILITY NUMBER: 274417517
VISIT DATE: 07/28/2025
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
The applicant was reminded that if he chooses to transport children, a valid driver’s license is required. Children cannot be left unattended in vehicles, car seats are for transportation only, and adequate booster seats and car seats must be available for safe transport.

Safe Sleep information was provided. The Licensee was reminded that an individual infant sleeping plan (LIC 9227) is required for each infant up to 12 months old, and 15 minute nap check documentation is required until age two.

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.

Applicant was provided with information that children's personal rights cannot be waived, even with authorization from a representative. These rights include being treated with dignity, receiving safe and healthful accommodations, and being free from corporal or unusual punishment

The applicant was provided information on his reporting requirements, including a copy of the Unusual Incident Form (LIC 624B), which outlines how, what, why, and when to report incidents that threaten the physical or emotional health and safety of any child.

The applicant confirmed that no Incidental Medical Services (IMS) would be provided at this time.

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 othis important information communication platforms.



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.
------CONTINUED ON NEXT PAGE-----
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
Page: 4 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, RAFAEL
FACILITY NUMBER: 274417517
VISIT DATE: 07/28/2025
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
On this date, 06/18/2025, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; thisefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant 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.

A notice of site visit was given to applicant and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

LPA conducted the inspection with an exit interview with Application Rafael Tapia.

Applicant was informed that a small Family Child Care Home License would be issued upon approval by licensing program manage

-----END OF REPORT -----

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5