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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403988
Report Date: 03/25/2022
Date Signed: 03/25/2022 03:19:53 PM

Document Has Been Signed on 03/25/2022 03:19 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:VILLALOBOS, SYLVIAFACILITY NUMBER:
434403988
ADMINISTRATOR:SYLVIA VILLALOBOSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 876-8807
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Silvia VillalobosTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA), Marilou Monico, met with Licensee, Silvia Villalobos, for an unannounced Required - 1 Year Inspection. LPA was granted access to the home by the Licensee and toured both indoor and outdoor areas during the inspection. There were no daycare children present. LPA observed all required posted materials. Days and hours of operation for the facility are Monday – Sunday, 7:00 AM- 6:00 AM. There are no active waivers or exceptions for this facility. Licensee states that she is the only adult residing in the home.

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 reviewed and obtained copy of facility roster (LIC9040). Fire/disaster drill was conducted on December 1, 2021 LPA observed a fully charged 3A40BC fire extinguisher, barricaded fireplace, and functioning smoke and carbon monoxide detectors. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. Licensee states 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
Continuation on next pages:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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 3
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: VILLALOBOS, SYLVIA
FACILITY NUMBER: 434403988
VISIT DATE: 03/25/2022
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Indoor licensed areas of the facility were inspected by LPA today and observed to be clean, orderly, and safe for the day care children. Off limit areas in the home: one bedroom, one bathroom, Entertainment Room, and garage. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as table, chairs/couches are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via filtered water and cups. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 876-8807.

The outdoor licensed areas of the home were inspected and observed to be fenced in. Off limit areas outside the home: Barbeque Area and both side yards. There were no bodies of water observed.

LPA 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 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.

Two (2) children’s files were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Affidavit Regarding Liability Insurance (LIC 282).

Licensee has Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and statement declining influenza. The Licensee has Mandated Reporter Training that expires on March 14, 2024. Licensee's CPR/First-Aid expires on March 28, 2023. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: VILLALOBOS, SYLVIA
FACILITY NUMBER: 434403988
VISIT DATE: 03/25/2022
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Supervision of children was discussed with the Licensee and she understands that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Silvia Villalobos.

As a result of todays inspection, there were no deficiencies cited.

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: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
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