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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354415930
Report Date: 06/16/2021
Date Signed: 06/16/2021 03:23:21 PM

Document Has Been Signed on 06/16/2021 03:23 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:WENZ, KATILYNFACILITY NUMBER:
354415930
ADMINISTRATOR:KATILYN WENZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 917-8083
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
06/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Katilyn WenzTIME COMPLETED:
03:30 PM
NARRATIVE
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LPA Deanna Villagrana met with licensee Katilyn Wenz for a Required 1 year visit, and explained the nature of today’s visit to her. LPA observed nine children in the home with licensee licensee's husband and assistant during today’s visit. Licensee's father was present but in an off limits area of the home. Days and hours of operation are Monday to Friday, 7:00am to 6:00pm. The adults that reside in the home are licensee, her husband and father.

A review of staff records on 06/15/2021 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 understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately removes the individual and prevents them from returning to the home or having contact with children in care.

LPA toured the indoor and outdoor areas of the home during today’s visit. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed no stairs inside the home and a barricaded fireplace and wood burning stove. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed shampoo, soap, a razor and air freshener accessible to children in the bathroom. LPA observed a fully charged 3A40BC fire extinguisher and a working combo smoke and carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: master bedroom, one bedroom, den, laundry closet and kitchen. Licensee has an additional bathroom that is used in case of emergency. LPA observed a fenced backyard and no bodies of water. Off limit areas outside the home: backyard including two locked storages. There are no animals in the home.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: WENZ, KATILYN
FACILITY NUMBER: 354415930
VISIT DATE: 06/16/2021
NARRATIVE
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LPA observed licensee has current CPR and First Aid certification expiring 06/26/2022. LPA observed a current roster of the children. LPA observed a fire and disaster drill log which was last done on 11/25/2020. LPA reviewed nine children files. Child 9 is missing LIC627. Child 9 immunization record is not complete. LPA observed Notification of Parents’ Rights is in each child’s file. Licensee, licensee's husband and assistant all have immunization records on file.

Supervision of children was discussed with 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. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed Zero Tolerance with $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee and licensee understands the requirements. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with licensee Katilyn, whose signature on this form confirms receipt of these documents.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2021 03:23 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 06/16/2021 at 02:44 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: WENZ, KATILYN
FACILITY NUMBER: 354415930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2021
Section Cited
CCR
102417(g)(4)

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Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
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Licensee removed items during visit. Deficiency cleared today.
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This requirement was not met as evidenced by LPA observed shampoo, soap, a razor and air freshener accessible to children in the bathroom. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.

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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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2021 03:23 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 06/16/2021 at 02:48 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: WENZ, KATILYN
FACILITY NUMBER: 354415930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2021
Section Cited
CCR
102417(g)(9)(A)

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Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement was not met as evidenced by LPA observed a fire and disaster drill log which was last done on 11/25/2020.
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Licensee will conduct a fire drill and submit proof to LPA by 06/23/2021.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
06/23/2021
Section Cited
CCR102417(g)(7)

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An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
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Licensee will submit LIC627 for child 9 by 06/23/2021 to LPA.
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This requirement was not met as evidenced by Child 9 is missing LIC627. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2021 03:23 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 06/16/2021 at 02:56 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: WENZ, KATILYN
FACILITY NUMBER: 354415930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2021
Section Cited
CCR
102418(g)

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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. This requirement was not met as evidenced by Child 9 immunization record is not complete.
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Licensee will submit current immunization record for child 9 to LPA.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
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