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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403847
Report Date: 02/08/2023
Date Signed: 02/08/2023 03:15:24 PM

Document Has Been Signed on 02/08/2023 03:15 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:ROMAN, ANGELAFACILITY NUMBER:
434403847
ADMINISTRATOR:ROMAN, ANGELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 761-0298
CITY:SAN JOSESTATE: CAZIP CODE:
95130
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Angela RomanTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs), Marilou Monico and Jovani Dillon, conducted an unannounced Required - 1 Year Inspection. LPAs met with Licensee, Angela Roman, and explained to her the nature of today's visit. Also present in the home were licensee's adult assistant and eight (8) daycare children including four (4) infants and four (4) preschool age. All required posted materials were posted by the entrance. The daycare is open Monday thru Friday from 7:00 AM to 6:00 PM. There are no active waivers or exceptions for this facility. Per Licensee, there are two adults residing in the home: herself and her husband.

LPAs toured the indoor and outdoor areas of the home. LPAs observed a fully charged 3A40BC fire extinguisher, functioning smoke and carbon monoxide detectors, and barricaded fireplace. Licensee states that there are no weapons or firearms in the home. LPAs observed a current children's roster and copy was obtained during the inspection. Fire/disaster drill was conducted on December 9, 2022.

Incidental Medical Services (IMS) policy was discussed. Licensee states that she is not planning to administer any medication at this time. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes, Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice 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

LPAs reminded licensee 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.

Continuation on next pages:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: ROMAN, ANGELA
FACILITY NUMBER: 434403847
VISIT DATE: 02/08/2023
NARRATIVE
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Off limit areas in the home now include: master bedroom, master bathroom, two bedrooms, and the garage. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible. LPAs observed sufficient age-appropriate materials, toys, and play equipment in the facility. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 761-0298. Off limit areas outside the home: both side yards. No bodies of water were observed.

LPA Monico discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

LPA Monico 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 she registers all infant devices with the CPSC to be notified of any recalls on her purchased equipment.

LPAs reviewed eight (8) children’s files for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Affidavit Regarding Liability Insurance (LIC 282), Identification and Emergency Information (LIC700), Immunization Records, and Notification of Additional Children in Care (LIC 9150).

LPAs reviewed a helper's file for the following records: Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), Employee Rights (LIC 9052), required immunizations, and TB test. Licensee's helper has no proof that she completed the Mandated Reporter Training. Licensee has expired Mandated Reporter Training. LPAs reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years. Licensee and her helper have current Pediatric CPR/First Aid certifications.

Continuation on next page:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
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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: ROMAN, ANGELA
FACILITY NUMBER: 434403847
VISIT DATE: 02/08/2023
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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


Exit interview conducted and report was reviewed with Angela Roman, Licensee.

As a result of today's inspection, deficiencies were cited on the following pages:

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
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Document Has Been Signed on 02/08/2023 03:15 PM - It Cannot Be Edited


Created By: Marilou Monico On 02/08/2023 at 02:33 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: ROMAN, ANGELA
FACILITY NUMBER: 434403847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, two children were sleeping in the play yards with pillows and one child was sleeping with a toy inside the play yard. This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 02/13/2023
Plan of Correction
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Licensee states she will submit a written plan of correction by 02/13/23 to ensure that nothing inside the crib while the child is sleeping.
Type B
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, blankets were hanging on the side of two of the play yards. This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 02/13/2023
Plan of Correction
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Licensee states she will submit a written plan of correction by 02/13/23 to ensure that no blankets will be hanged on the side of the play yard when a child is sleeping.
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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023


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Document Has Been Signed on 02/08/2023 03:15 PM - It Cannot Be Edited


Created By: Marilou Monico On 02/08/2023 at 02:33 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: ROMAN, ANGELA
FACILITY NUMBER: 434403847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 review of records, the licensee has expired Mandated Reporter Training and her helper has no proof that she completed the training. This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 03/22/2023
Plan of Correction
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Licensee states she will submit proof of current Mandated Reporter Training for Child Care Providers for her and her helper by 03/22/23.
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 review of records, Child #1 & #8 are missing the Individual Infant Sleeping Plan (LIC 9227) in their files. This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 02/13/2023
Plan of Correction
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Licensee states she will submit completed LIC 9227 for both children by 02/13/23.
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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023


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