434405858-5-10-2023-07-CC-AMOS-CRNUEP-20230509153125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434405858
Report Date: 05/09/2023
Date Signed: 05/10/2023 10:17:14 AM

Document Has Been Signed on 05/10/2023 10:17 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	HACKETT, JOSEPHINE		FACILITY NUMBER:	434405858
ADMINISTRATOR:	HACKETT, JOSEPHINE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 421-9127
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95054
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 9	DATE:	05/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Josephine Hackett		TIME COMPLETED:	02:50 PM

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	LPA Anna Morales conducted an unannounced Annual/Required Inspection. LPA met with Licensee, Josephine Hackett and her husband (staff). Present in the home were nine day care children (two infants over 12 months old and 7 preschool aged). Children were playing under the supervision of the Licensee and staff. Days and hours of operation are Monday - Friday from 7:30 AM -6:00 PM. Adults over the age of 18 and residing in the home are the Licensee and her spouse. All adults have Criminal Background Check Clearances. LPA was unable to review a Children's Roster. LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe. LPA did not observe any wall heaters inside the home. The fire place in the living room is barricaded. Off limit areas in the home: 3 bedrooms and front living room. There are no stairs inside the home. Off limit areas outside the home: detached garage & right side section of the backyard. Last disaster drill was conducted on 5/9/2023. LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water. The Licensee states that she does not have any pets or weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. (page 1)

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HACKETT, JOSEPHINE	FACILITY NUMBER: 434405858
	VISIT DATE: 05/09/2023

NARRATIVE

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Licensee stated that she does not transport children. Licensee stated she does not provide Incidental Medical Services (IMS).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. Licensee have an area where sick children can be isolated from the others until parent pick-up.

Licensee's and staff have current Mandated Reporter Training (AB1207) It expires in July 2023. LPA discussed Senate Bill 792, Assembly Bill (AB1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

Licensee's and staff files were reviewed for the following records: Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). Licensee has a current First Aid/CPR on file and it expires in July 2023.

LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent

LPA discussed the requirements of AB 633 with the Licensee and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HACKETT, JOSEPHINE	FACILITY NUMBER: 434405858
	VISIT DATE: 05/09/2023

NARRATIVE

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Exit Interview was conducted with Licensee. Deficiencies are being cited based on the LPA's observations, interviews conducted and records reviewed in accordance with the California Code of Regulations Title 22.

A NOTICE OF SITE VISIT WAS ISSUED AND LICENSEE WILL POST THIS FORM THIS FORM NEAR THE ENTRANCE OF THE HOME AND MUST REMAIN POSTED FOR 30 DAYS.

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/inspection-process

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 05/10/2023 10:17 AM - It Cannot Be Edited

Created By: Anna Morales On 05/09/2023 at 01:40 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: HACKETT, JOSEPHINE	FACILITY NUMBER: 434405858
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. Licensee has not documented 15 minute checks for C4 and C5 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2023
	Plan of Correction
1 2 3 4	Licensee will submit a plan to ensure that she will check and document every 15 minutes when infants are sleeping and submit by the POC date.

Type B

Section Cited

CCR

102417(g)(8)

Operation of A Family Child Care Home

(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. Licensee does not have a current Children's Roster, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2023
	Plan of Correction
1 2 3 4	Licensee will send a copy of the current roster to CCL by the POC date

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:

Anna Morales

LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6

Document Has Been Signed on 05/10/2023 10:17 AM - It Cannot Be Edited

Created By: Anna Morales On 05/09/2023 at 01:51 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: HACKETT, JOSEPHINE	FACILITY NUMBER: 434405858
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102421(b)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. Licensee couldn't locate C5 file and LPA was unable to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2023
	Plan of Correction
1 2 3 4	Licensee will submit completed forms for C5 to CCL by the POC date

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.

SUPERVISOR'S NAME:

Gladys Kuizon

LICENSING EVALUATOR NAME:

Anna Morales

LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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