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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274417885
Report Date: 07/24/2024
Date Signed: 07/24/2024 04:30:55 PM

Document Has Been Signed on 07/24/2024 04:30 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:FERNANDEZ, JAQUELINEFACILITY NUMBER:
274417885
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
07/24/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Jaqueline FernandezTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Andrea Cortez conducted an announced pre-licensing inspection to the home today July-24-2024. LPA met with Jaqueline Fernandez and explained the nature of today's inspection. The applicant states that herself, husband Christopher Fernandez, and 12-month-old infant lives in the home. Applicant is the homeowner. Applicant will provide an affidavit to parents that she does not carry insurance. The hours of operation are Monday through Friday 7:00AM to 6:00PM

LPA toured the indoor and outdoor areas of the home during inspection using the submitted LIC999A to confirm On and Off Limits:


Off Limits Areas: Upstairs Bedrooms 1,2, & 3, and Garage.
On Limit Areas: Kitchen, Living Room, Outside Sunroom and Bathroom.

LPA explained the Fire Drill Regulation to be conducted are every 6 months. Applicant will maintain a current children's' roster. The Applicant has a working cell phone in the home. LPA observed toys and play equipment for the day care children. All detergents, cleaning compounds, other similar items and poisons are inaccessible to children. Applicant shared they have a dog fully vaccinated and will be kept in the garage off limits to the children in care.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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: FERNANDEZ, JAQUELINE
FACILITY NUMBER: 274417885
VISIT DATE: 07/24/2024
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The Applicant understands the capacity ratios for a small home childcare. The Applicant states that she will not transport children and understands that children cannot be left in parked vehicles unattended at any time. Applicant understands that children's personal rights should not be violated, including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.

LPA observed a fully charged fire extinguisher in the playroom. There are working smoke & carbon monoxide detectors in the home. LPA did not observe any bodies of water. The Applicant understands that all pools, spas, hot tubs, fishponds, or similar bodies of water shall be covered or fenced as specified in Title 22 regulations to be inaccessible to children. Applicant states that there are no weapons or firearms in the home.

Incidental Medical Services (IMS) policy was discussed. Applicant currently does not offer. When any IMS is provided, an updated Plan of Operation that includes IMS and 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
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
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: FERNANDEZ, JAQUELINE
FACILITY NUMBER: 274417885
VISIT DATE: 07/24/2024
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LPA informed Applicant that Licensing forms and Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov

LPA reviewed the pre licensing packet with the Applicant.

LPA discussed the Individual Infant Sleeping plan and form 9227 with the Applicant.

Applicant does have current Mandated Reporter Certificate and will expire on 5-23-2026. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.


Applicant has a current CPR and First Aid card that expires 3-26-2026.
Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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