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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409237
Report Date: 06/26/2024
Date Signed: 06/26/2024 01:55:47 PM

Document Has Been Signed on 06/26/2024 01:55 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CAMACHO, EVAFACILITY NUMBER:
434409237
ADMINISTRATOR/
DIRECTOR:		EVA CAMACHOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 667-6050
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
06/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Alejandra Medina VillalobosTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee's assistant Alejandra Medina Villalobos for an annual/random visit. LPA explained the nature of today’s inspection to her. Present were licensee's assistant Alejandra Medina Villalobos and five day care children. Assistant Alejandra stated licensee went to a doctor's visit but did not know when she would return. Licensee was not present in the home during day care hours. Days and hours of operation are Monday to Friday, 6:00am to 6:00pm. The adults that reside in the home are licensee, her husband, 16 year old daughter and five year old son. Licensee lives in the bottom portion of the home. On the top portion is Alejandra, her husband, two adult daughters and 16 year old son.

A review of staff records on 06/19/2024 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee's assistant Alejandra Medina Villalobos 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 toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed barricaded stairs and fireplace in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged 3A40BC fire extinguisher, a working smoke and carbon monoxide detector. Licensee's assistant states there are no weapons/firearms in the home. Off limit areas indoor: one bedroom and entire upstairs. LPA observed a swimming pool that is fenced off to right of the home. There is a window to a bedroom that is located in the pool are and
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CAMACHO, EVA
FACILITY NUMBER: 434409237
VISIT DATE: 06/26/2024
NARRATIVE
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is not fenced off. Licensee uses bedroom where window is located for infants in care. Pool is not properly fenced and does not meet Title 22 regulations. Backyard is fenced. Off limits outdoor: right side of home that is fenced off to children including a storage and another locked storage in the back left side of the home. LPA observed two dogs and assistant states they are vaccinated. LPA observed licensee has a current CPR and First Aid certification expiring 03/04/2025 and completed Mandated Reporter training on 09/20/2022. Assistant Alejandra has a current CPR and First Aid certification expiring 05/18/2026 but has not completed Mandated Reporter training.

LPA observed a current roster of the children and a fire and disaster drill log which was last completed on 03/18/2024. LPA reviewed seven children's files. Child 6 immunization records need to be updated. Child 7 does not have immunization records and is missing LIC9227. Licensee's assistant states day care is not insured. LPA discussed SB792 Immunization Requirements and observed licensee's assistant does not have immunization records on file.



Supervision of children was discussed with licensee's assistant and she understands that she licensee must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee's assistant understands the capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee's assistant understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed the safe sleep regulations with licensee's assistant Alejandra Medina Villalobos 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's assistant Alejandra Medina Villalobos 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.


LPA discussed Zero Tolerance related regulations with licensee's assistant Alejandra Medina Villalobos and was advised of the assessment of $500 immediate civil penalty and an ongoing $100 per day per violation continues until the violation(s) is corrected. 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. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800)514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CAMACHO, EVA
FACILITY NUMBER: 434409237
VISIT DATE: 06/26/2024
NARRATIVE
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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.

Exit interview conducted and report was reviewed with the licensee's assistant Alejandra Medina Villalobos. During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The following type B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

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: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/26/2024 01:55 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 06/26/2024 at 01:20 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: CAMACHO, EVA
FACILITY NUMBER: 434409237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(5)
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: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence.

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 observed a swimming pool that is fenced off to right of the home. There is a window to a bedroom that is located in the pool are and is not fenced off. Licensee uses bedroom where window is located for infants in care. Pool is not properly fenced and does not meet Title 22 regulations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee will remove crib away from the bedroom window and will fence of the pool in the area were bedroom window is located.
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. Assistant Alejandra stated licensee went to a doctor's visit but did not know when she would return. Licensee was not present in the home during day care hours which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee will submit a statement stating she understands the above regulation and will close if she needs to be away from the facility more than 20 percent of her working hours.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/26/2024 01:55 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 06/26/2024 at 01:20 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: CAMACHO, EVA
FACILITY NUMBER: 434409237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Assistant Alejandra has not completed Mandated Reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee will submit a current Mandated Reporter certficate for Alejandra Medina Villalobos to CCLD by POC date.
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 interview, the licensee did not comply with the section cited above. Licensee's assistant does not have immunization records on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee will submit immunization record against pertussis, measles and influenza for assistant Alejandra Medina Villalobos to CCLD by 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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/26/2024 01:55 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 06/26/2024 at 01:20 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: CAMACHO, EVA
FACILITY NUMBER: 434409237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

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. Child 6 immunization records need to be updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee will submit updated immunization records for child 6 to CCLD by 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. Child 7 is missing LIC9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee will submit LIC9227 for child 7 to CCLD by 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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 06/26/2024 01:55 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 06/26/2024 at 01:31 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: CAMACHO, EVA
FACILITY NUMBER: 434409237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)


This requirement is not met as evidenced by: Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Child 7 does not have immunization records on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee will submit immunization records for child 7 to CCLD by 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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
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