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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274417690
Report Date: 07/12/2023
Date Signed: 07/12/2023 12:23:32 PM

Document Has Been Signed on 07/12/2023 12:23 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:VELAZQUEZ LOPEZ, MARIAFACILITY NUMBER:
274417690
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/12/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maria Velazquez LopezTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an announced pre-licensing inspection to the home today. LPA met with Maria S Velazquez Lopez, applicant, and explained the nature of today's inspection to her. Applicant states that herself and her spouse Gustavo are the adults residing in the home. Also in the applicant's home reside applicant's minor children ages 16, 12, and 3 years old.
Days and hours of operation will be Monday to Friday from 6:00 AM to 6:00 PM. Applicant understands that the children cannot stay in the home for more than 24 continue hours. Applicant has completed her Preventative Health and Safety Child Care Training included the lead poisoning training on 5/26/23. Applicant's pediatric CPR and First Aid certifications are current and will expire on 2/01/24. Applicant rents the home and a signed form LIC9149, and a copy of the rental agreement was requested today to place in the file. Applicant states does not have liability insurance for a family child care home (FCCH) and will use the Affidavit regarding liability insurance for Childcare (form LIC 282).
LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed there are not wall heaters in the home. LPA observed there are not bodies of water in the home. LPA observed the home does not have stairs. Off limits areas in the home are: Two bedrooms. Off limits areas outside are: The back yard and the driveway to the left side which is shared with the next door address 10982 Seymour Street. LPA observed the applicant's home does not have a garage or a right side yard. Applicant's home has a fenced front yard which will be used as playground. LPA observed applicant has a 3A40BC fire extinguisher in the home, and at least one working smoke detector. LPA observed the home has at least one working carbon monoxide (CO) detector. Applicant understands that prior to make any change related to the on or off limits must be reported to Licensing Program.
A review of staff records indicates that all the adults residing in the home or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

********************* Report dated 7/12/23 continues on page 2
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
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 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: VELAZQUEZ LOPEZ, MARIA
FACILITY NUMBER: 274417690
VISIT DATE: 07/12/2023
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*******Report dated 7/12/23 continues from page 1.

LPA observed the criminal records clearances for two adults have not been associated to this new facility yet and LPA obtained signed forms LIC9182 to associate applicant and her husband to this new facility.

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.

Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

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) or (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. Review of records to be maintained - Child Care Centers

LPA reviewed with applicant, the 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 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-andresources/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.

Report dated 7/12/23 continues on page 3.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: VELAZQUEZ LOPEZ, MARIA
FACILITY NUMBER: 274417690
VISIT DATE: 07/12/2023
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*******Report dated 7/12/23 continues from page 2.

On this date, 6/22/23 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; therefore, 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.

Exit interview conducted and report was reviewed with the applicant Maria Velazquez Lopez.

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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

Applicant was informed that an small Family Child Care Home license will be approved pending on the following: 1) Applicant will submit to Licensing Program with a signed copy of her rental agreement, 2) Approval from a manager of the Licensing Program.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC809 (FAS) - (06/04)
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