434403847-4-2-2025-07-CC-MMOO-DFCNPA-20250402103801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434403847
Report Date: 04/02/2025
Date Signed: 04/02/2025 11:14:34 AM

Document Has Been Signed on 04/02/2025 11:14 AM - 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:	ROMAN, ANGELA		FACILITY NUMBER:	434403847
ADMINISTRATOR/ DIRECTOR:	ROMAN, ANGELA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 761-0298
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95130
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 16	CENSUS: 11	DATE:	04/02/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:42 AM
MET WITH:	Angela Roman		TIME VISIT/ INSPECTION COMPLETED:	10:50 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On April 2, 2025 at 8:42 AM, Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Annual Random Inspection. LPA met with Licensee, Angela Roman. LPA was granted access to the home by Licensee. Also present in the home were Licensee's husband, Licensee's adult helper (S1), and nine daycare children: 1 infant and 8 preschool age. The Licensee received the Entrance Checklist (LIC 126). LPA observed all required postings. 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. Licensee stated that there are two adults residing in the home: herself and her husband. Two additional daycare children: 2 infants arrived during the inspection. LPA obtained a copy of current children's roster. Fire/disaster drill was completed on December 12, 2024. LPA observed a fully charged 3A40BC fire extinguisher installed in the kitchen. LPA observed functioning smoke and carbon monoxide detectors and barricaded fireplace. Licensee stated that there are no weapons or firearms in the home. Incidental Medical Services (IMS) policy was discussed. 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. Licensee, Angela Roman, 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. Continuation on next pages:

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Marilou Monico
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

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)

Page: 2 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: ROMAN, ANGELA	FACILITY NUMBER: 434403847
	VISIT DATE: 04/02/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Off limit areas inside the home: master bedroom, master bathroom, two bedrooms, and the garage. LPA observed that the home is clean and orderly. Cleaning products, sharp objects, and other hazardous items were stored inaccessible to children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. Off limit areas outside the home: left and right sides of the home. No bodies of water were observed.

LPA reviewed 11 children's files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), sleep log for children under 2 years old, Individual Infant Sleeping Plan (LIC 9227) for children under 12 months old, and Immunization Records.
LPA reviewed a helper's file (S1) for the following records: Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunizations, fingerprint clearance, TB test, and required training. S1's Mandated Reporter Training is expired. Licensee has the required immunizations and current Pediatric CPR/First Aid certifications with an expiration date of July 27, 2026. Licensee's Mandated Reporter Training expires on January 14, 2027. LPA reminded licensee that Mandated Reporter training must be renewed by all staff every 2 years.

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.

Continuation on next pages:

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Marilou Monico
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

Page: 3 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: ROMAN, ANGELA	FACILITY NUMBER: 434403847
	VISIT DATE: 04/02/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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.

Licensee, Angela Roman, was informed of the MyChildCarePlan.org site, 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.

As a result of this inspection, Type B deficiency was cited on the following page.

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

During the exit interview, the Licensee, Angela Roman, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A Notice of Site Visit was given to Licensee, Angela Roman, and must remain posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Marilou Monico
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 04/02/2025 11:14 AM - It Cannot Be Edited

Created By: Marilou Monico On 04/02/2025 at 10:05 AM

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: 04/02/2025

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
1 2 3 4	Based on record review, Licensee's helper (S1) has expired Mandated Reporter Training certificate which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/16/2025
	Plan of Correction
1 2 3 4	Licensee states that S1 will complete the training and will submit a current Mandated Reporter Training certificate to Licensing by 04/16/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:

	Marilou Monico
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

Page: 5 of 5