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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410679
Report Date: 08/20/2021
Date Signed: 08/23/2021 11:55:37 AM

Document Has Been Signed on 08/23/2021 11:55 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:NAVARRO, MARTHAFACILITY NUMBER:
434410679
ADMINISTRATOR:NAVARRO, MARTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 824-5439
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Martha NavarroTIME COMPLETED:
03:20 PM
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(1)LPA Janet Tse met with licensee Martha Navarro to conduct a required annual inspection. LPA explained the nature of today's visit to Licensee. Present were five children including one 16-month-old infant with Licensee and two assistants (AC & MC). Licensee is the only adult living in the home. LPA observed five visitors in the off-limits backyard area. Licensee and the visitors stated they were visiting from out of town three days ago, and they are leaving either next Monday or Tuesday. Days and hours of operation are Monday to Friday, 7:00am to 6:00pm.

LPA toured the inside and outside of the home. LPA observed no fireplace and no wall heaters. LPA observed no stairs inside the home. Off limits indoor: kitchen, master bedroom, master bathroom, and storage room. Licensee stated there is no firearms/weapons in the home. Sharp objects, medicines, poisons and cleaning supplies were stored inaccessible to the children. Storage areas for poisons are locked. Backyard is fenced. Off limits outdoor: backyard, driveway leading to the backyard, side yard, studio unit, and tool shed. Licensee stated children play in the front yard for outdoor activities. Licensee understands that children will be supervised when playing outdoor. LPA reminded licensee that she can only have 14 children according to her license. Licensee also understands her ratio and
Facility Evaluation Report dated 08/20/2021 to be continued on next page: - Pg 1 of 4 -
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Janet Tse
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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: NAVARRO, MARTHA
FACILITY NUMBER: 434410679
VISIT DATE: 08/20/2021
NARRATIVE
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Facility Evaluation Report dated 08/20/2021 to be continued from previous page (Pg 1):
capacity options.

Fire extinguisher is size 2A10BC and filled. Smoke and carbon monoxide detectors are operable. Home is clean and orderly with heating and ventilation for safety and comfort. LPA observed sufficient materials, toys, and play equipment for the daycare children. LPA observed Licensee is providing safe, healthful, and comfortable accommodations, furnishings, and equipment. Telephone is in working order.

Children were supervised on the visit and LPA went over substitute options. Licensee also understands that when a child shows signs of illness or communicable disease, he/she shall be separated from other children. LPA also discussed if licensee transports children, they are never to be left in parked vehicles.

A listing of staff criminal record clearances associated to this facility in Guardian system on 08/17/2021 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. LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100 per person per day,
Facility Evaluation Report dated 08/20/2021 to be continued on next page: - Pg 2 of 4 -
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Janet Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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: NAVARRO, MARTHA
FACILITY NUMBER: 434410679
VISIT DATE: 08/20/2021
NARRATIVE
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Facility Evaluation Report dated 08/20/2021 to be continued from previous page (Pg 2):
minimum of $100 to a maximum of $500 per person for an initial violation, and a minimum of $100 to a maximum of $3000 per person for any subsequent violation within a 12-month period.

LPA reviewed six children's files. LPA observed each child’s record has a copy of the emergency information card that contains all of the information specified by regulation. LPA observed Licensee has current Pediatric CPR/1st Aid expiring January 2023.

LPA discussed the immediate civil penalties for Zero Tolerance of $500, and an ongoing $100 per day per violation continues until the violation(s) is corrected. Licensee understands that when notified by the Department, Licensee shall comply with the removal of any person from the facility, who has specified convictions or for other reasons. LPA also discussed any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice.

LPA discussed the infant safe sleep policies, regulations, and requirements. LPA observed no documentation for infant sleep supervision which is to be maintained in each infant’s file includes date, infant’s name, and time of each 15 minutes check. Licensee also understands that car seats can only be used for transportation and shall not be used for sleeping.
Facility Evaluation Report dated 08/20/2021 to be continued on next page: - Pg 3 of 4 -
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Janet Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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: NAVARRO, MARTHA
FACILITY NUMBER: 434410679
VISIT DATE: 08/20/2021
NARRATIVE
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Facility Evaluation Report dated 08/20/2021 to be continued from previous page (Pg 3):
AB792 Immunization Requirements was discussed. LPA observed the required immunization records for Licensee and Licensee's assistants were in file.

The Mandated Reporter AB1207 Compliant Child Care Training was also discussed. Website to complete training: https://mandatedreporterca.com. A link to the alternate trainers approved to provide mandated reporter training: https://www.cdss.ca.gov/Portals/9/CCLD/CCP%20Documents/Approved%20Mandated%20Reporter%20Trainings.pdf. Licensee understands that the training is to be renewed every two years. LPA observed no certification of completion for the AB1207 Compliant Child Care Training for Licensee and her two assistants.

Website for provider resources: https://cdss.ca.gov/inforesources/Child-Care-Licensing. Periodic information releases accessible by signing up at: https://cdss.ca.gov/inforesources/community-care-licensing/subscribe.

Deficiencies were cited. Notice of site visit was issued and must be posted for 30 days.
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SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Janet Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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Document Has Been Signed on 08/23/2021 11:55 AM - It Cannot Be Edited


Created By: Janet Tse On 08/20/2021 at 02:21 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: NAVARRO, MARTHA
FACILITY NUMBER: 434410679

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2021
Section Cited
CCR
102425(j)

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The provider shall supervise infants while they are sleeping and adhere to the following requirements: (1) The provider shall physically check on sleeping infants every 15 minutes. (2) The provider shall document the following: ...
This requirement was not met as evidenced by:
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Licensee shall document the infant sleep supervision and forward a sample of the sleep supervision documentation and a copy of the infant's sleep supervision record to LPA by 08/30/2021 due date.
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 LPA observed no documentation for infant sleep supervision which is to be maintained in each infant’s file includes date, infant’s name, and time of each 15 minutes check.

This poses a potential risk to the Health, Safety, or Personal Rights to children in care.
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Type B
08/30/2021
Section Cited
HSC1596.8662(4)(b)(1)

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On or before March 30, 2018, a person who, on Jaunuary 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...
This requirement was not met as evidenced by:
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Licensee shall forward a copy of the certifications of completion for the AB1207 Compliant Child Care Training for Licensee and her two assistants to LPA by 08/30/2021 due date.
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LPA observed no certification of completion for the AB1207 Compliant Child Care Training for Licensee and her two assistants

This poses a potential risk to the Health, Safety, or Personal Rights to children in care.
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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:Janet Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021


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