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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412550
Report Date: 08/17/2022
Date Signed: 08/17/2022 11:34:50 AM

Document Has Been Signed on 08/17/2022 11:34 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:HEDMAN, ANNEFACILITY NUMBER:
434412550
ADMINISTRATOR:ANNE HEDMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 838-9682
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 7DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Phyllis HedmanTIME COMPLETED:
11:50 AM
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Licensing Program Analysts (LPA) Pete Hernandez conducted an unannounced Required 1 Year inspection to the home today. LPA met with Mother of Licensee , Phillis Hedman, and explained the nature of today's visit. Anne was out for a few hours at this time taking care of personal matters. Also present was her assistants, Valerie Rountree and Licensee's adult daughter Keshea Hedman. LPA observed 4 preschoolers and 3 infants. Days and hours of operation are Monday - Friday from 6:30AM to 6:00PM. The Licensee states that she and her Mother are the only adults that live in the home. Licensee's current CPR and First Aid expires on 9/25/2023. Phyllis Hedman has a current CPR and First Aid card in the absence of the Licensee: Expires 9/26/2023.

LPA toured the indoor and outdoor areas of the home during today's visit. Licensee's home is clean and orderly. Licensee is not currently watching children. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. LPA observed a blocked/covered fireplace wall heaters. LPA observed no stairs. Off limits indoor: the 2 bedrooms and the kitchen, and garage. There are no bodies of water. Licensee stated that there are no firearms/weapons in the home. Outdoor area is fenced. Licensee observed 2 locked storage shed in the backyard. Off limits outdoor: both side yards.

LPA observed a fully charged 3A40BC fire extinguisher in the kitchen. LPA observed and tested operational smoke and carbon monoxide detectors and fire pull station LPA observed no detergents, cleaning compounds, or medications accessible to children. They are all locked up from reach of the children. Emergency drill is current and done every 6 months.
A review of Staff records indicates that all persons that require a caregiver background check have received criminal record and child abuse index clearance or exemption. LPA informed Licensee of the applicable civil penalties for any adult who has not received fingerprint clearances, is not associated to the license and who comes in contact with or provides care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12- month period.
REPORT CONTINUED ON THE FOLLOWING PAGE (REPORT DATED 08/17/2022):
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HEDMAN, ANNE
FACILITY NUMBER: 434412550
VISIT DATE: 08/17/2022
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (REPORT DATED 08/17/2022):
Licensee and staff have current mandated reporter certificates expired on Licensee's expires 11/17/2022. LPA observed that the Licensee has completed the required Mandated Reporter Training (AB1207). Licensee's staff do not have the required immunization's against Pertussis and Measles on file. The Licensee has a decline statements on file for Influenza. LPA reviewed Three (7) children’s files. LPA observed that all children have the required Identification and Emergency Contact form (LIC700) and additional required documentation.
Supervision of children was discussed with the Licensee. Licensee stated that she is present 100 percent of the time during day care hours. The Licensee stated that she does transport children via vehicle and she understands the car seat laws and that children cannot be left in parked vehicles unattended at any time.

Licensee knows that Fire drills are required to be performed and recorded every 6 months: Most recent entry is 5/12/2022.
LPA went over the Individual Infant Sleep Plan form LIC9227 as it relates to care of infants.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov. The Mandated Reporter Training (AB1207) can be completed at the website listed, http://www.mandatedreporterca.com

Type A language: Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

No deficiencies are being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with the licensee. A copy of this report was discussed and left with the Licensee, Anne Hedman, whose signature on this form confirm receipt of these documents.
A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/17/2022 11:34 AM - It Cannot Be Edited


Created By: Pietro Hernandez On 08/17/2022 at 11:10 AM
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: HEDMAN, ANNE
FACILITY NUMBER: 434412550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

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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Per LPA's review of files, Assistants S1 and S2 do not have Mandated Reporter Training per AB1207. This poses a potential risk to the health and safety of children in care.
POC Due Date: 09/30/2022
Plan of Correction
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BY POC DUE DATE Assistant Providers S1 and S2 will complete the training and send a copy of the Certificate of Completion to Licensing Office. LPA provided the web address https://www.mandatedreporterca.com to access the required training.
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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Per LPA’s review, Staff 1 has been working at the family day care but does not have documentation that Staff 1 is immunized against Measles and Pertussis. This poses a potential risk to the health and safety of children in care.
POC Due Date: 09/19/2022
Plan of Correction
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BY POC DUE DATE: Licensee will obtain documentation of the required Measles and Pertussis immunization for Staff 1 and Staff 2. A copy of the documentation will be sent to the Licensing Office as proof of correction.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
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