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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416780
Report Date: 06/23/2022
Date Signed: 06/23/2022 09:33:26 PM

Document Has Been Signed on 06/23/2022 09:33 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:JIMENEZ ROA, ELVAFACILITY NUMBER:
354416780
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
06/23/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Elva Jimenez RoaTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Elizabeth Berumen and Araceli Almaraz conducted an announced pre-licensing change of location inspection to the home today. LPA notes that Elva applied for a large family child care license. LPAs met with Elva Jimenez Roa and explained the nature of today's visit to her. Elva was previously licensed at 830 Marne Drive in Hollister (354416085).
The adults that reside in the home are Licensee (Elva Jimenez Rao), spouse (Rosendo Mendoza Valencia) daughters' (Cielo Valencia-Jimenez) and (Dulce Valencia Jimenez).

Days and hours of operation will be Monday - Friday from 5:30am to 5:30pm. Licensee completed her Preventative Health and Safety Child Care Training on April 27, 2022. Mandated reporter training was completed on August 20, 2020. Licensee has immunization's against measles, pertussis, tb and declined the influenza vaccine.
Licensee's CPR and First Aid certifications are current and expire on 03/14/2024. Licensee rents the home and the Owner/Landlord Notification form (LIC 9151) is on file. Licensee has day care insurance and understands that if she does not have liability insurance she will issue the affidavit regarding liability insurance (LIC282) for FCCH to parents.

LPA inspected the indoor and outdoor areas during today's visit. Off limit areas in the home are master-bedroom, bedroom next to garage door, hall closet where washer and dryer are located, hall closet and garage. Off limit areas outside of the home are right side of backyard and storage shed. The right side of the yard has a fence to prevent children from accessing the area.
LPA observed a fully charged 3A40BC fire extinguisher. The smoke detector and carbon monoxide detector were tested and proved to be functioning. No bodies of water were observed. Licensee stated there are no weapons in the home. LPA observed a barricaded fire place in living room. There is a toy shelf barricading the fire place in the living/day-care room. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Licensee that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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: JIMENEZ ROA, ELVA
FACILITY NUMBER: 354416780
VISIT DATE: 06/23/2022
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Forms of discipline used by Licensee: Redirection. Licensee 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 reminded Licensee that fire/disaster drills must be practiced at least once every 6 months and documented. Licensee understands to always keep a current roster.

A fire safety clearance approved by the San Benito County fire department was approved on 05/27/22.

Licensee 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, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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-and-resources/safe-sleep as an additional resource. LPA also informed [applicant, licensee, or facility representative] 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.

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.

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.

Exit interview conducted and report was reviewed with the applicant Elva Jimenez Roa. Before a large license (capacity 14) can be approved: Criminal record clearances for four adults (Elva Jimenez Roa, Cielo Valencia Jimenez, Dulce Valencia Jimenez and Rosendo Mendoza Valencia) will be transferred from 354416085 to this facility 354416780.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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