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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409235
Report Date: 09/09/2022
Date Signed: 09/09/2022 02:16:10 PM

Document Has Been Signed on 09/09/2022 02:16 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:LOPEZ, ZOILAFACILITY NUMBER:
434409235
ADMINISTRATOR:ZOILA LOPEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 531-1656
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 9DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Zoila LopezTIME COMPLETED:
11:45 AM
NARRATIVE
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On 09/09/2022 at 09:44 AM, Licensing Program Analyst (LPA) Teodoro Trujillo and Licensing Program Manager (LPM) Mary Segura met with licensee, Zoila Lopez, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee, assistant and licensee boyfriend with 9 children: six preschool and three infants. Adults living in the home are licensee and her boyfriend Milton. Days and hours of operation are Monday through Friday 6:00 AM to 5:30 PM.
A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 09/06/2022 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 and LPM inspected inside and outside of the home. LPA and LPM 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 2A10BC fire extinguisher last serviced on 11/04/2020. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored on top kitchen cabinet. Off limit areas: second floor. Outside on backyard LPA observed multiple cans of paints accessible to children. 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 09/09/2022 pg. 1/2

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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Document Has Been Signed on 09/09/2022 02:16 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 09/09/2022 at 01:05 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: LOPEZ, ZOILA
FACILITY NUMBER: 434409235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

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, license has a fire extinguisher that was last serviced on 11/04/2020, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2022
Plan of Correction
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Licensee will submit proof of service or purchase a new fire extinguisher and will submit proof of service or receipt to the San Jose Regional Office by close of business 09/12/2022.
Type B
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, the licensee did not comply with the section cited above, licensee has multiple can of paints in back left area of yard, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2022
Plan of Correction
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Licensee will provide proof of storing or disposing of accessible paint in back yard to the San Jose Regional Office by close of business 09/12/2022.
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: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2022 02:16 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 09/09/2022 at 01:05 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: LOPEZ, ZOILA
FACILITY NUMBER: 434409235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, licensee assistant file has no proof of Measels and pertusis vacination, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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Licensee will submit proof vaccinations to the San Jose Regional Office by the end of business 09/23/2022.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, C1 file has missing LIC 700 and C2 file has missing signature, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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Licensee will have C1 parents fill and sign LIC 700 and C2 parents signn LIC 700 and mail a copy of signed documents to the San Jose Regional Office by end of business 09/23/2022.
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: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/09/2022 02:16 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 09/09/2022 at 01:05 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: LOPEZ, ZOILA
FACILITY NUMBER: 434409235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022

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 and record review, the licensee did not comply with the section cited above, C1 file has missing LIC 9227, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2022
Plan of Correction
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Licensee will obtain completed and signed LIC 9227 and submit copy to the San Jose Regional Office by close of business 09/12/2022.
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: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


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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: LOPEZ, ZOILA
FACILITY NUMBER: 434409235
VISIT DATE: 09/09/2022
NARRATIVE
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Continuation of report dated 09/09/2022 pg. 2/2
LPA and LPM observed a fire and disaster drill log that was last conducted on 05/11/2022. LPAs reviewed 11 children’s files, C1 was missing LIC 700 and C2 LIC 700 missing parent signature . The 15 minute check sleep log for infants under 24 months was discussed, licensee provided completed sleep logs, LPA reviewed and observed they were in compliance. LPA observed that the Licensee has Mandated Reporter training, training was completed on 10/06/2021, assistant Irene has not completed, hired on 07/09/2022.. Licensee has Pediatric CPR/1st Aid expiring 02/19/2023, assistant Irene expiring on 6/14/2024. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is missing for assistant Irene.

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.

Type B deficiencies were cited during today's visit. 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, Zoila Lopez. 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: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
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