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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412224
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:48:37 PM

Document Has Been Signed on 06/20/2023 04:48 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:DELGADO, MARIA DEL CARMENFACILITY NUMBER:
434412224
ADMINISTRATOR:DELGADO, MARIA DEL CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 603-8341
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Maria Del Carmen DelgadoTIME COMPLETED:
05:30 PM
NARRATIVE
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On 06/20/2023 at 09:10 AM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee Maria Del Carmen Delgado, for an annual inspection. Present with licensee were assistant Natalia with 11 children: eight (8) infants and three (3) preschool age, one preschool age child is licensee daughter. Licensee is over capacity for her license. Parents of 4 infant children were called to during site visit. Adults living in the home are licensee, her spouse Alfonso and her minor child. Days and hours of operation are Monday through Friday 07:15 AM to 04:45 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 5/11/2023 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have not received criminal record and child abuse index clearances or exemptions. Assistant Natalia has not obtained criminal background clearance or transferred her criminal background clearance, assistant has assisted licensee since 05/01/2023. 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 inspected inside and outside of single-story home. License rents the home and does not have LIC 9149 Property Owner/Landlord Consent and states does have liability insurance for a family child care home (FCCH). LPA observed a barricaded fireplace, no wall heater, no stairs, and no bodies of water. LPA observed covered patio has dry rot throughout the 2 x 6 holding the top structure, licensee states landlord is working on replacing roof. Licensee states she has no pets. LPA observed a 3A40BC fire extinguisher, licensee stated she last purchased in 2020 and has not been serviced. Carbon Monoxide and smoke detectors are operable. Sharp objects, medicines, poisons, and cleaning supplies were accessible to children in care, bathroom sink cabinet had soap and toilet cleaning supplies, kitchen sink cabinet had a bottle of Mr. Clean cleaner and was accessible. Off limit areas inside the home: master bedroom with bathroom and attached garage. On limit areas: living room, day care room and two bedrooms. Backyard is fenced. Off limits outdoor: gated right and left side fenced yard area. On limit areas outside the home: rear yard play area with porch.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 12 children according to her license. Licensee stated she does 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 report dated 06/20/2023 pg 1/3
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 14
Document Has Been Signed on 06/20/2023 04:48 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/20/2023 at 01:48 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: DELGADO, MARIA DEL CARMEN
FACILITY NUMBER: 434412224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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, interview, the licensee did not comply with the section cited above in, on limit bathroom kitchen cabinet had antibacterial toilet cleaner, hand soap, bubble bath soap, and foaming toilet cleaner, kitchen sink cabinet had a 1.33 liter bottle of Mr. Clean which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Licensee immediately removed all accessible items and stored them in the locked off limit garage.
Type A
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in door to off limit room used as Infant Nap room was shut with Child 3 (C3) and Child C7 two sleeping infants which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Door to infant nap was opened by licensee during site.
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 2 of 14
Document Has Been Signed on 06/20/2023 04:48 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/20/2023 at 01:48 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: DELGADO, MARIA DEL CARMEN
FACILITY NUMBER: 434412224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in, criminal background transfer request/clearance has not been obtained for assistant Natalia, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Licensee will obtain criminal background check/transfer request for assistant Natalia by close of business 06/21/2023 and assistant will not assist or be present until transfer request or background check is done.
Type A
Section Cited
CCR
102416.5(d)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, cord review, the licensee did not comply with the section cited above in licensee was providing childcare to 8 infant children during site inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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deficiency cleared during site inspection, parents of 4 infants were called and they picked up the infant children during site visit.
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 06/20/2023 04:48 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/20/2023 at 01:48 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: DELGADO, MARIA DEL CARMEN
FACILITY NUMBER: 434412224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

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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Based on observation, interview, record review, the licensee did not comply with the section cited above in Outdoor covered patio cross beams have visible dry rot damage, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
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Licensee will submit a written plan on how she will correct the deficiency and will not use the covered patio area for child care use. Licensee states she is going to replace covered patio. Licensee will submit proof of completed work by a licensed construction company and/or city inspection.
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) (interview) (record review)], the licensee did not comply with the section cited above in licensee does not have proof of purchase or proof of yearly fire extinguisher service, licensee states fire extinguisher purchased in 2020 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
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Licensee will submit proof of purchase of a new fire extinguisher or proof of service by close of business on 07/05/2023 to the San Jose Regional Office
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 06/20/2023 04:48 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/20/2023 at 01:48 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: DELGADO, MARIA DEL CARMEN
FACILITY NUMBER: 434412224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in, Last fire drill conducted 12/06/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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Licensee will submit a copy of fire drill to the San Jose Regional Office by close of business 06/23/2023.
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
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Licensee will submit a written statement of her understanding of the regulation to the San Jose Regional Office by close of business 07/05/23.
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 06/20/2023 04:48 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/20/2023 at 01:48 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: DELGADO, MARIA DEL CARMEN
FACILITY NUMBER: 434412224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(j)
Admission Procedures and Authorized Representatives Rights
(j) Copies of the signed receipt shall be available to the Department as provided in Section 102391(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in Child C5 and C9 missing signature, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
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Licensee will submit a copy of signed LIC 995A to the San Jose Regional Office by close of business 07/05/2023.
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) (interview) (record review)], the licensee did not comply with the section cited above in assistant Natalia does not have proof of pertussis vaccination, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Licensee will submit proof of vaccine for assistant Natalia by close of business 07/07/2023.
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 06/20/2023 04:48 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/20/2023 at 01:48 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: DELGADO, MARIA DEL CARMEN
FACILITY NUMBER: 434412224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

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

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Child 2 (c2), c3, c4, c5, c6, c7, c8, c9 missing immunization records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
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Licensee will submit proof of vaccinations to the San Jose Regional by close of business 07/05/2023.
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
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in, Child 1 (C1), c2, c3, c4, c5, c6, c7, c8, c9 missing CDPH286] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
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Licensee will submit copies of the CDPH 286 for children to the San Jose Regional Office by close of business 07/05/2023.
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 06/20/2023 04:48 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/20/2023 at 01:48 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: DELGADO, MARIA DEL CARMEN
FACILITY NUMBER: 434412224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in, Roster has not been updated, missing information of 6 children in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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2
3
4
Licensee will submit a copy of updated roster to the San Jose Regional Office by close of business 06/21/2023.
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
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in LIC 9227 missing for Infant Child 3 (c3), c4, c5, and c7, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
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2
3
4
Licensee will submit a copies of LIC 9227 to the San Jose Regional Office by close of business 07/05/2023.
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 8 of 14
Document Has Been Signed on 06/20/2023 04:48 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/20/2023 at 01:48 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: DELGADO, MARIA DEL CARMEN
FACILITY NUMBER: 434412224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in infant sleep log missing for child 1(c1), c2, c3, c4, c5, c7, c8, and c9, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
1
2
3
4
Licensee submit copies of sleep logs to the San Jose Regional Office by close of business 07/05/23.
Section Cited
Deficient Practice Statement
1
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:Mary Segura
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 9 of 14
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: DELGADO, MARIA DEL CARMEN
FACILITY NUMBER: 434412224
VISIT DATE: 06/20/2023
NARRATIVE
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Continuation of report dated 06/20/2023 pg. 2/3
LPA observed a roster of the children that has not been updated. LPA observed a fire and disaster drill log last performed on 12/06/2022. LPA reviewed 11 children’s files and observed not all required documentation was in compliance. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was discussed, missing for Child 3 (c3), c4, c5, and c7 and a 15-minute check sleep log for infants under 24 months was not provided for child 1(c1), c2, c3, c4, c5, c7, c8, and c9. LPA observed licensee assistant Natalia completed Mandated Reporter Training on 01/11/2023 and licensee and assistant Maria Luisa do not proof of completion of Mandated Reporter Training. Licensee and assistant Maria Luisa has Pediatric CPR/1st Aid expiring on 02/11/2025 and assistant Natalia expiring on 07/26/2024. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is current for licensee, and assistant Maria Luisa, assistant Natalia is missing proof of pertussis vaccine.

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 currently. 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.

Continues report dated 06/20/2023 pg. 2/3

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 12 of 14
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: DELGADO, MARIA DEL CARMEN
FACILITY NUMBER: 434412224
VISIT DATE: 06/20/2023
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Continuation of report dated 06/20/2023 pg. 3/3
Type A deficiencies were cited during today's visit. LPA Teodoro Trujillo informed licensee Maria Del Carmen Delgado that this report dated 06/20/2023 document(s) 3 (three) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA Teodoro Trujillo informed the licensee Maria Del Carmen Delgado to provide a copy of this licensing report dated 06/20/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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, Maria Del Carmen Delgado. 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: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 13 of 14
Document Has Been Signed on 06/20/2023 04:48 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 06/20/2023 at 04:26 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: DELGADO, MARIA DEL CARMEN
FACILITY NUMBER: 434412224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

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 observation, interview, record review, the licensee did not comply with the section cited above in licensee and assitant Maria Luisa have not renewed Mandated Reporter Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
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Licensee will submit a copy copies of completed Mandated Reporter Training to the San Jose Regional Office by close of business 07/05/2023.
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
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