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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412550
Report Date: 09/13/2021
Date Signed: 09/13/2021 12:44:47 PM

Document Has Been Signed on 09/13/2021 12:44 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:HEDMAN, ANNEFACILITY NUMBER:
434412550
ADMINISTRATOR:ANNE HEDMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 838-9682
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
09/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Anne HeadmanTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPA) Pete Hernandez conducted an unannounced Required 1 Year inspection to the home today. LPA met with Licensee, Anne Hedman, and explained the nature of today's visit. Also present was her assistant, Athena Morningstar. There was 1 schoolage, 2 preschoolers and 1 infant. Days and hours of operation are Monday - Friday from 6:30AM to 6:00PM. The Licensee states that she and her Mother and adult Daughter are the only adults that live in the home. Current CPR and First Aid expired on 5/18/2021.

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 09/13/2021):
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HEDMAN, ANNE
FACILITY NUMBER: 434412550
VISIT DATE: 09/13/2021
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CONTINUATION OF PREVIOUS PAGE (REPORT DATED 09/13/2021):
Licensee's mandated reporter certificates expired on 1/21/2021. LPA observed that the Licensee has not completed the required Mandated Reporter Training (AB1207). Licensee does have the required immunization's against Pertussis and Measles on file. The Licensee has a decline statements on file for Influenza. LPA reviewed Three (3) 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.

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.

Two 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: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/13/2021 12:44 PM - It Cannot Be Edited


Created By: Pietro Hernandez On 09/13/2021 at 12:02 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: HEDMAN, ANNE
FACILITY NUMBER: 434412550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2021
Section Cited
CCR
102416(c)

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Personnel Requirements. The Licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary resuscitation
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BY POC DUE DATE Licensee agrees to provide proof of CPR/First Aid completion to Licensing office
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Per LPA's review of file, Licensee does not have current Pediatric CPR/First Aid certification on file. This poses a potential risk to the health and safety of children.
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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:Sandy Knight
LICENSING EVALUATOR NAME:Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2021 12:44 PM - It Cannot Be Edited


Created By: Pietro Hernandez On 09/13/2021 at 12:06 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: HEDMAN, ANNE
FACILITY NUMBER: 434412550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2021
Section Cited
HSC
1596.8662(b)(1)

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On or before March 30, 2018, a person who on, January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training […] and shall complete renewal […] every two years […] This requirement is not met as evidenced by:
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BY POC DUE DATE Licensee and Assistant Provider 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.
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Per LPA's review of files, Licensee dos not have Mandated Reporter Training per AB1207. Licensee stated she was unaware of the requirement. This poses a potential risk to the health and safety of 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:Sandy Knight
LICENSING EVALUATOR NAME:Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2021


LIC809 (FAS) - (06/04)
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