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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409640
Report Date: 11/22/2024
Date Signed: 11/22/2024 03:41:24 PM

Document Has Been Signed on 11/22/2024 03:41 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:HERNANDEZ, LORENAFACILITY NUMBER:
434409640
ADMINISTRATOR/
DIRECTOR:		LORENA HERNANDEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 334-9528
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 3DATE:
11/22/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:22 PM
MET WITH:Lorena HernandezTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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At 12:22 PM, Licensing Program Analysts (LPAs) Andy Yang and Syeda Bahar met with Licensee, Lorena Hernandez to conduct an unannounced annual random inspection. Present for this inspection were Licensee, Staff, (3) Children (1 infant and 2 pre-school age). The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from Monday to Friday 6:00 AM to 6:00 PM.

The home is single family home. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are living room, bedroom, kitchen, dining room, family room, and backyard. The OFF LIMIT AREAS are garage, master bedroom, and master bathroom is inaccessible by closed and/or locked doors and visual supervision. Licensee stated that the on limit and off limit areas have changed from the sketch in file. Licensee has provided updated sketch LIC 999. The ISOLATION AREA is dining room. The outdoor play area is free from defects and is fenced. There are ample age-appropriate toys that appear to be safe and in good condition. There are no bodies of water. LPA observed hazardous materials and toxins which were accessible to children in the family room, bathroom, and backyard. LPA reminded the Licensee that poisons, detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. Licensee states that any poisons are stored in garage which is OFF LIMITS. LPA reminded Licensee that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes.

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SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HERNANDEZ, LORENA
FACILITY NUMBER: 434409640
VISIT DATE: 11/22/2024
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The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The Licensee CPR and First Aid certificate is current and expires 4/15/2025. Licensee completed the Mandated Reporter Training for Child Care Providers on 7/2022 (expired 7/2024) and a copy of the certification is on file. Licensee was reminded of Mandated Reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the licensee’s immunization is on file. Per Licensee, there are no firearms in the home. The Licensee conducts and documents fire and disaster drills every six months. Personnel record and immunization record were not available for review for staff S1. LPA reminded the Licensee that The family day care home shall maintain documentation of the required immunization or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the family day care home. Child’s records are available for review. LPA identified that Individual Infant Sleep Plan LIC 9227 was missing from child C1's file. LPA reminded the Licensee that Each infant under 12 months of age will have an Individual Infant Sleeping Plan maintained in the file signed and dated by the infant’s authorized representative, including the infant’s sleeping position and documentation of 15 minute checks while sleeping. All REQUIRED forms are posted and visible for public review.

Forms of discipline to be used by Licensee are redirecting and talking with the child. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature.

Also, discussed with the Licensee was isolation of sick children, supervision of children, staffing ratio and capacity, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated

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SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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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: HERNANDEZ, LORENA
FACILITY NUMBER: 434409640
VISIT DATE: 11/22/2024
NARRATIVE
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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-andresources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE, Lorena Hernandez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Megan's Law was checked on 11/18/2024.

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SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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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: HERNANDEZ, LORENA
FACILITY NUMBER: 434409640
VISIT DATE: 11/22/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

During today’s inspection, seven “Type B” deficiencies are issued on attached 809-D. Appeal rights provided.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Lorena Hernandez.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 11/22/2024 03:41 PM - It Cannot Be Edited


Created By: Andy Yang On 11/22/2024 at 02:40 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: HERNANDEZ, LORENA
FACILITY NUMBER: 434409640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on inspection of the home, LPAs identified adult care products (razors, rubbing alcohol, and self care products) in the bathroom, and knives on the kitchen counter which were accessible to children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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2
3
4
During the time of inspection, the Licensee has removed the items in the bathroom and place in inaccessible area and removed the knives and placed in inaccessible area.
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 inspection of the on limit family room, LPA observed nail products and acetone that wer accessible to children, and observed in the backyard that anit-freeze and gasoline bottles were accessible to children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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By POC due date of 11/27/2024, Licensee will show proof of the living room cleared of nail products and items, and show proof of backyard cleared of items that are harmfull to children.
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:Belinda Devall
LICENSING EVALUATOR NAME:Andy Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 11/22/2024 03:41 PM - It Cannot Be Edited


Created By: Andy Yang On 11/22/2024 at 02:40 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: HERNANDEZ, LORENA
FACILITY NUMBER: 434409640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

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 file review, Licensee and Staff do not have completed Mandated Reporter training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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By POC due date of 12/06/2024, Licensee and Staff will provide proof of completion of the Mandated Reporter training.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review of Staff S1, Staff was missing Employee RIghts LIC 9052 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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By POC due date of 12/06/2024, Licensee will provide copy of Staff's Employee Rights LIC 9052.
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:Belinda Devall
LICENSING EVALUATOR NAME:Andy Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 11/22/2024 03:41 PM - It Cannot Be Edited


Created By: Andy Yang On 11/22/2024 at 02:40 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: HERNANDEZ, LORENA
FACILITY NUMBER: 434409640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

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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3
4
Based on Staff's record review, staff was missing immunization record which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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3
4
By POC due date of 12/06/2024, Licensee will provide proof of staff's immunization record and TB test.
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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2
3
4
Based on record review of child C1's file, child was missing Individual Infant Sleep Plan LIC 9227 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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2
3
4
By POC due date of 11/27/2024, Licensee will provide copy of Individual Infant Sleep Plan LIC 9227 for child C1.
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:Belinda Devall
LICENSING EVALUATOR NAME:Andy Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 11/22/2024 03:41 PM - It Cannot Be Edited


Created By: Andy Yang On 11/22/2024 at 02:40 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: HERNANDEZ, LORENA
FACILITY NUMBER: 434409640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
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: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review for child C1's file, child was missing 15 minute check log poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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2
3
4
By POC due date of 11/27/2024, Licesnee will provide proof of the 15 minute documented sleep log.
Section Cited
Deficient Practice Statement
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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:Belinda Devall
LICENSING EVALUATOR NAME:Andy Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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