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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407719
Report Date: 05/05/2022
Date Signed: 05/10/2022 11:26:40 AM

Document Has Been Signed on 05/10/2022 11:26 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CAGIGAO, ROSAFACILITY NUMBER:
434407719
ADMINISTRATOR:CAGIGAO, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 969-9930
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rosa CagigaoTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Morales conducted an unannounced Annual Required visit and was greeted by Licensee Rosa Cagigao. The centers hours of operation are Monday - Friday, 7:30am-7:00pm. The Licensee and her mother reside at the home. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Last disaster drill was completed on 3/16/2022

LPA observed three infants ( two under twelve months old, one over 12 months and one preschool aged children).

LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. The day care room is the back room, where there are high chairs, chairs, sufficient materials, toys, and play equipment for the day care children. Licensee stated that she supervises the children while they play out in the backyard. The home is clean and orderly. LPA did not observe any wall heaters or fire place inside the home. Off limit areas inside the home: four bedrooms, 1 master bathroom, laundry room, garage, and studio in the backyard. Off-limit areas outside: left side yard, four storage sheds, and spa (with secure and locked cover).

LPA observed a fully charged 2A10BC fire extinguisher and a working smoke detector. LPA did not observe a carbon monoxide detector. The Licensee states that she does not have any pets and weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children.


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SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: CAGIGAO, ROSA
FACILITY NUMBER: 434407719
VISIT DATE: 05/05/2022
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. Licensee stated that she used to provide IMS services, however, she does not at this time. 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 has an area where sick children can be isolated from the others until parent pickup.

Licensee's Mandated Reporter Training (AB1207) expired on 7/14/2021. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (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.

A random selection of 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 Immunization Records (PM286).

Licensee's 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 on 9/8/2023

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
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
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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: CAGIGAO, ROSA
FACILITY NUMBER: 434407719
VISIT DATE: 05/05/2022
NARRATIVE
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LPA Morales observed two infants files who did not have an INDIVIDUAL INFANT SLEEPING PLAN(LIC9227) completed and observed one infant sleeping on his/her stomach and one infant sleeping on his/her side. Licensee stated that they are able to roll on their own.

LPA discussed and left a copy of Pin 20-24-CCP, RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT. Discussed that all INFANTS UP TO 12 MONTHS OF AGE MUST HAVE AN INDIVIDUAL INFANT SLEEPING PLAN (LIC9227) ON FILE, WHICH WILL DOCUMENT THE INFANTS SLEEPING HABITS, USUAL SLEEPING ENVIRONMENT, AND THE INFANT ROLLING ABILITIES. PROVIDERS MUST CONDUCT CHECKS EVERY 15 MINUTES ON SLEEPING INFANTS (UP TO TWO YEARS OLD). 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.

Licensee will submit a copy of the 15 minute check for infant(s) up to to age 2.

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.

Exit Interview was conducted with Licensee. Type B deficiency cited and a copy of this report was provided to the Licensee.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO 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: Diana Stephenson
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
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Document Has Been Signed on 05/10/2022 11:26 AM - It Cannot Be Edited


Created By: Anna Morales On 05/05/2022 at 03:45 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: CAGIGAO, ROSA
FACILITY NUMBER: 434407719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

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, LPA did not observe Carbon Monoxide Dectector, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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Licensee stated that she will place the Carbon Monoxide Detector back in the Day care room and send photos to CCL by the POC date
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 record review, the licensee did not comply with the section cited above in two infants(C2 and C3) under twelve months old which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Licensee will send a complete LIC9227 for C2 and C3 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:Diana Stephenson
LICENSING EVALUATOR NAME:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


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Document Has Been Signed on 05/10/2022 11:26 AM - It Cannot Be Edited


Created By: Anna Morales On 05/05/2022 at 04:13 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: CAGIGAO, ROSA
FACILITY NUMBER: 434407719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in not having a current Mandated Reporting Traning. Her certificate expired on 7/14/2021, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee will submit a copy of the certificate to CCL by the POC date
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:Diana Stephenson
LICENSING EVALUATOR NAME:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


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