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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403886
Report Date: 05/28/2024
Date Signed: 05/28/2024 02:27:41 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/28/2024 02:27 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:RAYA, JUNEFACILITY NUMBER:
434403886
ADMINISTRATOR/
DIRECTOR:		RAYA, JUNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 254-4956
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
05/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:June RayaTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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On 5/28/24 around 12:40pm Licensing Program Analyst (LPA) Sheena Chin conducted an unannounced Case Management - annual continuation inspection at the facility and met with June Raya, the licensee. Present were the licensee, a helper and 9 children in care in the facility.

The fire clearance the department had was denied for a different address in 2005. The licensee stated that she never had a license for that address. The licensee stated that she had the fire clearance for the current facility but did not email it to LPA. After looking through the files, the licensee located the fire safety inspection request, STD 850 in 2000. LPA observed that on the STD 850 the option of fire clearance granted was not circled but the form had the inspector’s signature. When reviewing files, LPA observed that the helper did not have MMR immunization records in the file.

A regulatory violation was observed during the inspection and a citation was issued.

Exit interview was conducted, where this report, the citation, plan of correction, and appeal rights were reviewed and discussed with Licensee, June Raya.
Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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 05/28/2024 02:27 PM - It Cannot Be Edited


Created By: Sheena Chin On 05/28/2024 at 02:11 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: RAYA, JUNE
FACILITY NUMBER: 434403886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
HSC
1597.622(a)(1)

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1597.622(a) (1)... a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles....
This requirement was not met as evidenced by :
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The licensee will send LPA the copy of the helper's MMR immunication records.
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Based on record review, the licensee did not comply with the section cited above. The helper did not have MMR immunization records in the file, which poses a potential Health, Safety, and Personal Rights risk to persons 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:Gladys Kuizon
LICENSING EVALUATOR NAME:Sheena Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024


LIC809 (FAS) - (06/04)
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