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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406525
Report Date: 10/13/2022
Date Signed: 10/13/2022 05:15:57 PM

Document Has Been Signed on 10/13/2022 05:15 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:PAZ REYES, MARIA DE LOURDESFACILITY NUMBER:
434406525
ADMINISTRATOR:PAZ, MARIA LOURDESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 224-3023
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Maria Paz ReyesTIME COMPLETED:
05:30 PM
NARRATIVE
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On 10/13//2022 at 1:25 PM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Maria Paz Reyes, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee with 4 children: three preschool and one infant. Adults living in the home are licensee, husband Victor and two adult children. Days and hours of operation are Monday through Friday 7:00 AM to 6:00 PM.
A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 10/4/2022 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 a covered fireplace inside the home, inoprable wall heater, no stairs and no bodies of water. Licensee stated there are no weapons. Licensee stated they have two small birds as pets. LPA observed a new and fully charged 3A40BC fire extinguisher. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Off limit areas: Garage, three bedrooms. Off limit outside: enclosed left and right side back yard, locked storage shed. 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 10/13/2022

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PAZ REYES, MARIA DE LOURDES
FACILITY NUMBER: 434406525
VISIT DATE: 10/13/2022
NARRATIVE
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Continuation of report dated 10/13/2022 pg. 2/2
LPA observed a fire and disaster drill log that was last conducted on 9/30/2022. LPA reviewed 5 children’s files and observed all required documentation was in compliance. The 15 minute check sleep log for infants under 24 months was discussed, licensee has not started sleep logs, LPA reviewed and observed they were not in compliance. LPA observed that the Licensee has Mandated Reporter training, training was completed on 4/29/2021. Licensee has Pediatric CPR/1st Aid expiring 10/8/2024. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee.

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. PIN 22-02-CCP was provided to licensee.

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.

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.

Type B deficiencies were cited during today's visit, documented the LIC809-D. Exit interview conducted and report was reviewed in Spanish with the licensee, Maria Paz. 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: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2022 05:15 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 10/13/2022 at 03:46 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: PAZ REYES, MARIA DE LOURDES
FACILITY NUMBER: 434406525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, sleeping infant inside bassinet on top of play pen has a cover and elephant toys hanging from the top, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2022
Plan of Correction
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Licensee immediately cleared deficiency by removing sleeping infant from bassinet and bassinet was removed from the top of play pen.
Type B
Section Cited
CCR
102425(j)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements:

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, 15 min check has not been documented for C1, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2022
Plan of Correction
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Licensee will start a safe sleep log documenting 15 min sleep check for infant C1 in care and will provide a copy of safe sleep log to the San Jose Regional office by close of business 10/14/2022.
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: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/13/2022 05:15 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 10/13/2022 at 03:46 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: PAZ REYES, MARIA DE LOURDES
FACILITY NUMBER: 434406525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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, infant C1 in care is missing LIC 9227, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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Licensee will provide a completed LIC 9227 for infant C1 to the San Jose Regional Office by close of business 10/28/2022.
Type B
Section Cited
CCR
102425(j)(2)(D)
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:

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, Safe sleep log has not been started for infant C1, licensee was not aware of log, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2022
Plan of Correction
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Licensee will start a safe sleep log for C1 and submit a copy to the San Jose Regional Office by close of business 10/14/2022.
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: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
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