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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274417581
Report Date: 11/02/2023
Date Signed: 11/02/2023 04:57:08 PM

Document Has Been Signed on 11/02/2023 04:57 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:PEREZ, JUANAFACILITY NUMBER:
274417581
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
11/02/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Juana PerezTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an unannounced annual inspection to the home today. LPA met with Juana Perez, Licensee, and explained the nature of today's inspection to her. Days and hours of operation are Monday to Saturday from 4:00 AM to 10:00 PM. The adults that reside in the home are the Licensee, her partner Juvenal, and her daughter Nancy. Also in the home resides licensee's 15 years old minor daughter. Present during today's inspection was an infant child.
Licensee's certifications for CPR and First Aid are current and will expire on 6/27/25.

LPA toured the indoor areas of the home during today's inspection. Licensee did not produce a current Child Care Facility Roster during today's inspection. LPA reviewed the Fire/Disaster drill log during today's visit. Last fire drill was documented on 8/14/23. LPA reviewed four children's files and are complete including a Parent's Rights form and the immunization records form. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. LPA observed the home has central A/C and heating. Off limit areas in the home are the second floor, a bedroom in the first floor, the laundry room, and the attached garage. Off limits outside the right side of the back yard. There are barricaded stairs in the home.

LPA observed a fully charged 2A10BC fire extinguisher last serviced 8/24/23, working smoke and carbon monoxide detectors and no bodies of water. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children. Licensee has in file immunization records for pertussis, measles, and flu vaccines according with the SB792.


********************Report dated 11/02/23 continues in page 2.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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 6
Document Has Been Signed on 11/02/2023 04:57 PM - It Cannot Be Edited


Created By: Fermin Campos-Jaramillo On 11/02/2023 at 03:40 PM
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: PEREZ, JUANA
FACILITY NUMBER: 274417581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

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 has not documented the infants sleep every 15 minutes, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Licensee shall submit to licensing Program before 11/16/23 a copy of the log documenting the infant sleep for the period 11/03/23 to 11/14/2023. (log provided to licensee) Licensee will continue documenting the infants sleep until they reach the age of two years old.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

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 produce a current children's roster, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Licensee shall complete a children's roster and will submit a copy to licensing program by 11/16/23.
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:Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/02/2023 04:57 PM - It Cannot Be Edited


Created By: Fermin Campos-Jaramillo On 11/02/2023 at 03:40 PM
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: PEREZ, JUANA
FACILITY NUMBER: 274417581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023

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 did not have a form LIC9227 signed by parents in the infant file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Deficiency cleared today as parent fill up the form during the inspection.
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:Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


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: PEREZ, JUANA
FACILITY NUMBER: 274417581
VISIT DATE: 11/02/2023
NARRATIVE
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Report dated 11/02/23 continues from page 1.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 8 children in the home at any time and ratio (age of the children) must be observed. The Licensee states that she does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.

Department website: www.ccld.ca.gov provided to Licensee.

LPA observed that licensee has renewed the "Mandated Reporter" training on 7/13/22. Licensee is aware that training shall be renewed every two years and all the adults in contact with children shall complete the training. LPA provided licensee with the training website www.mandatedreporterca.com for additional information.

A review of staff records on 10/31/23 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
Licensee was reminded that all the 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.
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource.

Report dated 11/02/23 continues in page 3

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
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: PEREZ, JUANA
FACILITY NUMBER: 274417581
VISIT DATE: 11/02/2023
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***************Report dated 11/02/23 continues from page 2.
LPA also informed licensee 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.

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: https://www.ada.gov/resources/child-care-centers/.

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 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.

During the exit interview, the LICENSEE Juana Perez confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



Exit interview conducted and report was reviewed with the licensee Juana Perez.
There were three type B deficiencies 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 handed to licensee and must remain posted for 30 days.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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