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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274418042
Report Date: 12/30/2025
Date Signed: 12/30/2025 01:03:56 PM

Document Has Been Signed on 12/30/2025 01:03 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:CALDERON JIMENEZ, BETZABETHFACILITY NUMBER:
274418042
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/30/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Calderon Jimenez, BetzabethTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 12/30/2025, Licensing Program Analyst (LPA) Liridon Fici- Doni conducted an announced Pre-Licensing Inspection in response to a request for a change of location. LPA met with Calderon Jimenez, Betzabeth, Applicant, and explained the nature of today’s visit. LPA notes that the Applicant is not currently licensed at 1002 Walnut Avenue, Greenfield, CA 93927 (Facility number: 274417999).

The Applicant states that adults, over the age of 18, residing in the home is the applicant, and her spouse. The Applicant has three (3) minor children living in the home. LPA advised that children living in the home will be included in the home ratio and capacity until they turn 10 years of age. The hours of operation for the family child care home (FCCH) will be Monday - Friday, 5:00AM-8:00PM and the Applicant is planning to offer care for children ages zero (0) months to 12 years old. The Applicant has submitted a lease agreement and does not currently have liability insurance for the day care. LPA advised the Applicant to provide parents with Affidavit Regarding Liability Insurance (LIC282) upon registration until liability insurance is purchased in the future.

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.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Liridon Fici
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2025
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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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)
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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: CALDERON JIMENEZ, BETZABETH
FACILITY NUMBER: 274418042
VISIT DATE: 12/30/2025
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LPA toured inside the home and observed sufficient materials and play equipment for day care children. LPA observed the home has a central heating system. The front of the home is properly set-up for caring for infants including soft materials covering the floor, toys, and a baby changing table. Off limits inside the home include: All Bedrooms, and garage. Off limits to the outside of the home include: front of the home, and the sides of the backyard. LPA advised if there are changes to the on/off limits of the home to submit an updated facility sketch (LIC999A) to the San Jose Regional Office. There is a working cell phone at the FCCH. The Applicant currently has two (2) infants cribs and 12 cots and with blankets for children's napping. LPA advised that mattress sheets should be changed between infants, if the crib is shared, and infant sheets shall be washed daily. LPA did not observe any bodies of water during inspection.

The Applicant states that she will not provide medication and Incidental Medical Services to children. The Applicant states that all formula will be provided by the parents of children enrolled and she will prepare and cook hot meals as needed at her home. Children will bring water in water bottles if needed. The Applicant has two (2) high chairs available for feeding infants. LPA observed kitchen knives properly stored inaccessible to children in the off limits area in the kitchen above the cooking stove. There are no firearms in the home.

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 Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. Applicant stated she will not care for children who need IMS plans.

The Applicant is planning to care for infants and has a baby changing pad, waste bin with a tight-fitting lid, and proper storage for diapers and wipes. There is a sink that is easily accessible in the kitchen for use, if needed.


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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Liridon Fici
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
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: CALDERON JIMENEZ, BETZABETH
FACILITY NUMBER: 274418042
VISIT DATE: 12/30/2025
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The Applicant states that she is currently planning to use any outdoor space for caring for children. LPA advised that if she plans to not use outdoor space in the future, to submit an updated facility sketch (LIC999A).

LPA observed fully charged 2A10BC fire extinguisher, functioning smoke detector and carbon monoxide detector. LPA advised completing annual maintenance for the fire extinguisher. The Applicant was provided fire/emergency disaster drill log and was advised drills should be completed every 6 months.

The Applicant states that for discipline of the children, Licensee stated she will speak to the children to ensure they understand along with examples to the child. If the child continues to misbehave, she will speak to the child and give other options to comfort the child. Applicant also stated she will use redirection and 1:1 time with the child as needed. LPA advised that if utilized, the recommended duration for "time out" is 1 minute per year of age for the child. The Applicant understands that children's personal rights should not be violated; including no corporal punishment. Children should not be left for extended periods of time in furniture such as a high chair or play pen.

LPA discussed isolation of sick children with the Applicant and she stated the child will not be admitted into care. If a child were to start feeling sick at her home, she will take temperatures and call parents as needed; If the child is fussy, not eating, or a change of routine, parents will be called. The child will would be isolated on a napping mat next to the front door entrance or in the family room where Applicant can supervise the child, until the parent/guardian arrives to pick-up. LPA discussed isolation strategies, such as using a baby gate, and utilizing the restroom if the child's symptoms need close restroom access. LPA observed the Applicant has a first-aid kit, and thermometer, available in her home.

LPA additionally discussed supervision of children, unusual incidents (LIC624B), and requirements for additional staff/ adults living in the home. The Applicant states that she does plan to transport children if she needs to. The Applicant additionally understands that she must be home at least 80% of the time FCCH is open.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Liridon Fici
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
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: CALDERON JIMENEZ, BETZABETH
FACILITY NUMBER: 274418042
VISIT DATE: 12/30/2025
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LPA reviewed small family child care home capacity requirements with the Applicant and provided copy of 102416.5 Staffing Ratio and Capacity from California Code of Regulations. The Applicant is not planning to care for more than six children at any time. There should never be more than four infants, children under two years of age, present at the FCCH.

LPA reviewed with the Applicant 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 required postings with Applicant and provided copies of Parents Rights bulletin (PUB394) and Earthquake Preparedness Checklist (LIC9148). LPA discussed Provider Information Notices (PINs). LPA additionally reviewed CCLD website and online annual fee payment.

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 discussed the safe sleep regulations with the Applicant and provided 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 informed Applicant that Infants 12 months (1 Year old) and under will use the Lic9227 (Individual Infant Sleep Plan) and conduct 15-minute sleep logs, and Infants 1 year old and above will continue the 15-minute sleep log until age 2 years old.



The Applicant 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.

LPA advised the Applicant that a small FCCH license will be issued pending manager review and approval. Exit interview conducted and report was reviewed and provided to the Applicant, Calderon Jimenez, Betzabeth.
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Liridon Fici
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC809 (FAS) - (06/04)
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