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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434405376
Report Date: 03/16/2023
Date Signed: 03/16/2023 01:40:15 PM

Document Has Been Signed on 03/16/2023 01:40 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:MADRIGAL, MARIAFACILITY NUMBER:
434405376
ADMINISTRATOR:MADRIGAL, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 998-7403
CITY:SAN JOSESTATE: CAZIP CODE:
95110
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
03/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Maria MadrigalTIME COMPLETED:
02:15 PM
NARRATIVE
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On 03/16/2023 at 08:50 AM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Maria Madrigal, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee, assistant(A2) Brenda, licensee spouse and adult duaghter with 8 children: seven preschool and one infant. Adults living in the home are licensee and her husband Jose and adult daughter Dianna. Days and hours of operation are Monday through Friday 6:00 AM to 6:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 03/07/2023 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 the home. LPA observed no fireplace inside the home, no wall heater, barricaded stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated they have no pets. LPA observed a fully charged 3A40BC fire extinguisher last serviced on 04/13/2022. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines are inaccessible to the children and stored on top kitchen cabinet. Toothpaste and personal hygene products were accessible in unlocked bathroom sink, in room adjacent to garage. Kitchen cleaning supplies were accessible under unlocked kitchen sink cabinet. Off limit indoor areas: all second floor rooms and attached garage. Off limit areas outside: gated left yard area. Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to their license. Licensee stated they do 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 on report dated 03/16/23 pg. 1/3

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 03/16/2023 01:40 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 03/16/2023 at 12:01 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: MADRIGAL, MARIA
FACILITY NUMBER: 434405376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023

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, two 24 oz counter top cleaners and dish soap under kitchen sink, 7oz. spray can of concentrated room deodorizer and toothpaste in bathroom next to kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2023
Plan of Correction
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licensee moved cleaning products and bathroom deoderizor and toothpaste to top washroom cabinet, making items inaccessible 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: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023


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Document Has Been Signed on 03/16/2023 01:40 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 03/16/2023 at 12:01 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: MADRIGAL, MARIA
FACILITY NUMBER: 434405376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

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 inLicensee has not documented the 15-minute check for infant Child 1 (C1), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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Licensee will sumbit completed sleep logs for C1 to the San Jose Regional Office by close of business 03/24/2023.
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: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023


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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: MADRIGAL, MARIA
FACILITY NUMBER: 434405376
VISIT DATE: 03/16/2023
NARRATIVE
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Continuation of report dated 03/16/23 pg. 2/3
LPA observed a fire and disaster drill log that was last conducted on 02/16/2023. LPA reviewed 5 children’s files. The 15 minute check sleep log for infants under 24 months was discussed, licensee provided sleep logs that does not document the 15-minute sleep check for Child (C1). LPA reviewed and observed they were not in compliance. LPA observed that the Licensee has Mandated Reporter training, training was completed on 07/21/2022, assistant (A2) Brenda has completed on 07/21/2022, (A3) Diana has completed 11/14/2022. Licensee has Pediatric CPR/1st Aid expiring 07/10/2023, (A2) expiring on 07/25/2024, (A3) expiring 03/01/2024. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file.

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 at this time. 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 on report dated 03/16/23 pg. 2/3

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

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
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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: MADRIGAL, MARIA
FACILITY NUMBER: 434405376
VISIT DATE: 03/16/2023
NARRATIVE
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Continuation of report dated 03/16/23 pg. 3/3

Type A deficiencies were cited during today's visit. LPA Teodoro Trujillo informed licensee Maria Madrigal, that this report dated 03/16/2023 document(s) 1 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 Maria Madrigal to provide a copy of this licensing report dated 03/16/2023 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, Maria Madrigal. 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: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
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