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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274417773
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:29:49 PM

Document Has Been Signed on 04/18/2024 04:29 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:MELGOZA, MARIAFACILITY NUMBER:
274417773
ADMINISTRATOR/
DIRECTOR:
FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/18/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Maria MelgozaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 04/18/24, at 12:55 P.M., Licensing Program Analysts (LPA) Teodoro Trujillo met with Applicant, Maria Melgoza, to conduct an announced pre-licensing inspection. LPA was granted access to the home by the Applicant. Applicant, spouse Juan were the only adults present, no children in care today. The Applicant, her spouse Juan, are the adults residing in the home. There are three (3) minor children residing in the home: 14-year-old, 13-year-old and 10-year-old.

Days and hours of operation will be Monday - Friday from 06:00 AM to 06:00 PM. Applicant completed her Preventative Health and Safety Child Care Training on 12/10/2022. Applicants CPR and First Aid certifications are current and expire on 04/01/2025. Copies of both certifications are on file. LPA observed applicant completed the Mandated Reporter Training for Child Care Workers on 06/01/2023, a copy of the certification is on file. A copy of current TB test, flu, Mmr, and Tdap vaccinations for the Applicant are on file. Applicant owns the home and a copy verifying control of property is on file. Applicant understands that she cannot care of more than eight (8) children at any time. Applicant does not have liability insurance and will issue Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282).
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LPA toured the indoor and outdoor areas of the home with the Applicant during today's inspection. The Applicant's home is two-story home with bottom studio unit with an attached garage on 1.3 acre property. LPA observed outside stairs leading to second floor living area in the home during today's inspection. Day care area is located on the first-floor studio that has a gate preventing access to 2nd floor living area for applicant. LPA observed no wall heaters in the home. LPA observed no fireplace in the home. Applicant states that she will operate the day care in the following areas: first floor bedroom, bathroom, living room and kitchen. On limit outside: right side gated play area. Off limit areas inside the home: all of 2nd floor and attached garage. Off limit outside: left yard area and rear yard areas.

The home is clean, orderly, (including heating/air conditioning), and ventilation for safety & comfort. Applicant does have sufficient toys, supplies, and equipment for the day care children for both indoors and outdoors. LPA observed a fully charged fire extinguisher (2A10BC), working carbon monoxide/smoke detector. Applicant states that she does not have any weapons/ammunition in the home.

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SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MELGOZA, MARIA
FACILITY NUMBER: 274417773
VISIT DATE: 04/18/2024
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Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Applicant that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes. Applicant states that she will not administer any medication to the children at this time. Applicant states that a child will be isolated in the living room, if necessary due to illness or communicable disease. Applicant has a First Aid kit in the home.

Applicant understands that children's personal rights should not be violated, including no corporal punishment. isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 04/18/24 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions Applicant Maria Melgoza was reminded that all 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 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 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 provided and reviewed 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. LPA also discussed the importance of maintaining records for any person/assistant providing care to the children and children in the home under 10 years of age.

LPA discussed the safe sleep regulations with applicant Maria Melgoza 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 licensee Maria Melgoza 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.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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: MELGOZA, MARIA
FACILITY NUMBER: 274417773
VISIT DATE: 04/18/2024
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APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:
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

PIN 22-02-CCP - Best Practices Related to the Provision of Incidental Medical Services in Child Care Center and Family Care Homes was provided to Applicant.

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 provided the applicant the Department website: www.ccld.ca.gov

Applicant Maria Melgoza was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare 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 Melgoza, and LPA advised her that a Small Family Child Care Home License is approved, pending Licensing Program Manager.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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