434412779-8-10-2022-07-CC-FCJO-CH76J8-20220810205039

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434412779
Report Date: 08/10/2022
Date Signed: 08/10/2022 08:51:02 PM

Document Has Been Signed on 08/10/2022 08:51 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:	GONZALEZ, ARCELIA		FACILITY NUMBER:	434412779
ADMINISTRATOR:	GONZALEZ, ARCELIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 310-0239
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95111
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 8	CENSUS: 5	DATE:	08/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Arcelia Gonzalez		TIME COMPLETED:	12:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) met with licensee Arcelia Gonzalez for an unannounced annual inspection. Present were five children including two infants, and three preschool children. Licensee's helper Elena was also in the home. Licensee's 7 years old child was also in the home. Adults living in the home are Licensee, her husband, and two tenants, Narcisa and Juan, who are living in the converted garage. Days and hours of operation are Monday to Friday from 6:00am to 6:00pm. LPA toured the indoor and outdoor of the home. LPA observed a blocked/covered fireplace and no wall heaters. Off limits indoor: three bedrooms, the converted garage which is a studio that consists of one bathroom, a kitchen, and an open area. There are no bodies of water. Licensee stated there is no firearms/weapons in the home. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Backyard is fenced. LPA observed a locked storage unit in the fenced off limits area. Off limits outdoor: left side yard where the storage shed is located. LPA reminded licensee that she can only have 14 children according to her license. 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 day care children. Telephone is in working order. Children were supervised all the time by licensee and her helper. LPA also discussed if licensee transports children, they are never to be left in parked vehicles. LPA reviewed eight children's files. LPA observed that in 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 completed training on preventive health practices, and has current Pediatric CPR expiring on 8/21/23. Licensee was requested to update the LIC279 to show the names of the current tenants. Report dated 8/10/22 continues on page 2.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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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Document Has Been Signed on 08/10/2022 08:51 PM - It Cannot Be Edited

Created By: Fermin Campos-Jaramillo On 08/10/2022 at 11:46 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: GONZALEZ, ARCELIA	FACILITY NUMBER: 434412779
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 records review the licensee did not comply with the section cited above in one case. Form LIC9227 is missing in the infant L.T. file. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2022
	Plan of Correction
1 2 3 4	Licensee shall obtain a complete form LIC9227 from parents of infant L.T. and submit a copy to licensing Department on or before August 25, 2022.

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:

Fermin Campos-Jaramillo

LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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: GONZALEZ, ARCELIA	FACILITY NUMBER: 434412779
	VISIT DATE: 08/10/2022

NARRATIVE

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Report dated 8/10/22 continues from page 1.

LPA observed that licensee and her helper have renewed the Mandated Reporter training on 2/07/22 Website to complete training: https://mandatedreporterca.com. Licensee understand that the training is to be completed every two years..

LPA observed licensee and her helper have in file proof of immunization for measles, pertussis and influenza according with the SB792.

A review of staff records on 8/09/22 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
Licensee Arcelia Gonzalez 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 discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

Report dated 8/10/22 continues on page 3.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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: GONZALEZ, ARCELIA	FACILITY NUMBER: 434412779
	VISIT DATE: 08/10/2022

NARRATIVE

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Report dated 8/10/22 continuers from page 2.

Incidental Medical services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

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.

Exit interview conducted and report was reviewed with licensee Arcelia Gonzalez

A type B deficiency was cited today.

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

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC809 (FAS) - (06/04)

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