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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434402043
Report Date: 05/09/2023
Date Signed: 05/09/2023 01:43:32 PM

Document Has Been Signed on 05/09/2023 01:43 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:SIVIRA, CARMENFACILITY NUMBER:
434402043
ADMINISTRATOR:SIVIRA, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 749-8302
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Carmen SiviraTIME COMPLETED:
02:00 PM
NARRATIVE
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On 05/09/2023 at 9:10 AM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee Carmen Sivira, for an annual inspection and explained the reason for the visit to her. Present during today's visit was assistant Fiorella with 7 children: two (2) infants and four (4) preschool age, Assistant Rosa arrived at the same time as LPA, and infant child arrived during site inspection. Adults living in the home are licensee, and her spouse. Days and hours of operation are Monday through Friday 07:00 AM to 6:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 5/8/2023 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. Licensee was reminded that all adults 18 and over living or working in the home, 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 inspected inside and outside of single-story home. LPA observed a barricaded fireplace, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons. LPA observed on cat. LPA observed a 3A40BC fire extinguisher last serviced on 08/02/2022. Carbon Monoxide and smoke detectors are operable. Licensee observed the off limits kitchen was not barricaded at arrival, and was accessible to children, two spray bottles of Lysol and two bottles of hand sanitizer were in bottom kitchen cabinet. LPA observed licensee adult father visiting in the home. Off limits indoor: master bedroom, master bathroom, two bedrooms, kitchen, and garage. Backyard is fenced. Off limits outdoor: Off limits outdoor: both side yards.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to her license. Licensee stated she does not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.

Continues report dated 05/09/2023 pg. 1/3

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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Document Has Been Signed on 05/09/2023 01:43 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 05/09/2023 at 12:05 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: SIVIRA, CARMEN
FACILITY NUMBER: 434402043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in, two spray bottles of Lysol and two bottles of hand sanitizer were accessible in bottom kitchen cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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Licensee immediately removed Lysol and hand sanitizer to off limit locked garage during site visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2023 01:43 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 05/09/2023 at 12:05 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: SIVIRA, CARMEN
FACILITY NUMBER: 434402043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in, right side yard has a 15' ladder and a 7' large dead tree old day care toys, and a covered plastic container filled with water and car parts and oil in children play area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee will submit proof of clearing right side area or install a gate to make right side area inaccessible to children in care, to the San Jose Regional Office by close of business 05/24/2023.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in, assistant Rosa and assistant Fiorella have not started or completed Mandated Reporter Training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee will submit a copies of assistants proof of completion certificate of Mandated Reporter Training to the San Jose Regional Office by close of business 05/24/2023.
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:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


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Document Has Been Signed on 05/09/2023 01:43 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 05/09/2023 at 12:05 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: SIVIRA, CARMEN
FACILITY NUMBER: 434402043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in Roster has not been updated with the date five children who left the family day care home and date of admission of two children currently in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Licensee will submit a copy of the updated Roster to the San Jose Regional Office by close of business 05/12/23.

Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in, Child 1 and Child 3 files missing LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee will obtain completed and signed LIC9227 and will submit copies to the San Jose Regional Office by close of business 05/24/2023.
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:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


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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: SIVIRA, CARMEN
FACILITY NUMBER: 434402043
VISIT DATE: 05/09/2023
NARRATIVE
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Continuation of report dated 05/09/2023 pg. 2/3
LPA observed a roster that needs to be updated of the children in care. LPA observed a fire and disaster drill log last performed on 04/12/2023. LPA reviewed 6 children’s files and observed all required documentation was not in compliance. Infant individual sleeping plan (LIC 9227) for each infant under 12 months is missing for Child 1 (C1) and C3. 15-minute check sleep log for infants under 24 months was provided. LPA observed licensee completed Mandated Reporter Training on 01/30/2023, assistant Fiorella and Rosa have not started nor completed Mandated Reporter Training. Licensee has Pediatric CPR/1st Aid expiring on 08/22/2023 and both assistants respectively expire on 1/09/2025. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is current for licensee, and all adults residing in the home.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS currently. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

LPA discussed the safe sleep regulations with licensee 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 licensee 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Continues report dated 05/09/2023 pg. 2/3

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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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: SIVIRA, CARMEN
FACILITY NUMBER: 434402043
VISIT DATE: 05/09/2023
NARRATIVE
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Continuation of report dated 05/09/2023 pg. 3/3
Type A deficiencies were cited during today's visit. LPA Teodoro Trujillo informed licensee Carmen Sivira that this report dated 05/09/2023 document(s) 1 (one) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA Teodoro Trujillo informed the licensee Carmen Sivira to provide a copy of this licensing report dated 05/04/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.
Exit interview conducted and report was reviewed in Spanish with the licensee, Carmen Sivira. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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