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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412947
Report Date: 11/12/2024
Date Signed: 11/12/2024 12:23:38 PM

Document Has Been Signed on 11/12/2024 12:23 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ANTONI, STEPHANIEFACILITY NUMBER:
434412947
ADMINISTRATOR/
DIRECTOR:		ANTONI, STEPHANIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 394-5536
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
11/12/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Stephanie AntoniTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Antoni, Stephanie, for an unannounced Required- Annual Inspection. LPA was granted access to the exterior of the home by the Helper and licensee was called. Licensee joined five minutes later. LPA toured the exterior of the home and part of the garage with the staff person. Upon arrival, there were 5 children (preschool age) and 3 staff present, which is compliant with the home license capacity and ratio requirements. LPA observed none of the required postings near the entrance of the day care. LPA asked licensee if they were posted elsewhere and she stated they were not posted anywhere. LPA reminded licensee that Parent's Rights Pub and facility license should always be posted near the door. Hours of operation for the facility are Monday – Friday, 08:00AM-01:00PM. There are no active waivers.

Licensee states that she is the only adult living in the home. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Licensee did not have an LIC9040 completed, but did have a roster available on her laptop. LPA printed a Roster for licensee and asked her to email a copy of her roster for records. Licensee provided a fire/disaster drill log during today's inspection. The last fire/disaster drill was conducted on 10/17/2024, which is compliant with the six-month requirement for homes. LPA observed a 2A10BC fire extinguisher but it had not been serviced since 1/14/2021 which is not compliant with Fire Marshall regulations. LPA reminded licensee that a fire extinguisher must be serviced each year or replaced. LPA tested the CO2 detector in the bathroom hallway and it did not work. Licensee located a working smoke detector/carbon monoxide detector and installed it in the hallway/laundry room.

Continued on Page 2
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ANTONI, STEPHANIE
FACILITY NUMBER: 434412947
VISIT DATE: 11/12/2024
NARRATIVE
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Licensee states that she does not currently have any children in care who require Incidental Medical Services. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

The Licensee states that there are no weapons or firearms in the home.

Indoor areas of the home were not inspected by the LPA today because licensee states she no longer conducts her day care in the home. The day care is set up under a Permanent pergola on the patio area of the backyard. There is a cement floor, temporary tented ceilings and walls in one portion. LPA observed age appropriate play structures, cubbies for children's affects. There are tables and chairs set up, shelves with activities and an outdoor sink for kids to wash their hands. The backyard had a wooden play structure and a sandbox. LPA observed a play area in the back of the yard that was covered in mud and debris. Mud and sand were inside the structure. Licensee stated this was a mud playing space. Off-limits areas of the day care are now the Garage, side yards, front yard and the entire home. The garage door was locked, LPA observed a bathroom used for children in care. LPA observed the bathroom to have cobwebs in the ceiling, surfaces had a layer of dust and floor had dirt and debris. LPA reminded licensee the requirement is for indoor and outdoor areas to be clean and orderly for children in care.

Drinking water is readily available for children in the facility via water bottles from home, if they run out for the day licensee will fill them up from a filtered water faucet in the kitchen. The Licensee uses her cell phone for the working telephone in the facility. There are no stairs in the day care.

Licensee stated she does not have any children under 24 months 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.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
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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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ANTONI, STEPHANIE
FACILITY NUMBER: 434412947
VISIT DATE: 11/12/2024
NARRATIVE
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 3 children’s files were reviewed during today's inspection and the following documents were present: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700). Not present in any of the files: immunization records or the PM286 and Affidavit Regarding Liability Insurance (LIC282).

1 staff file was reviewed. Present in the file: Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza declination. There is at least one staff member present with current CPR/First-Aid that expires 05/08/2026. The Licensee stated that mandated reporter has not been completed by any staff member in the past two years. LPA reminded that training must be renewed by all staff every 2 years. Licensee did not have a file for her second helper.

Supervision of children was discussed with the Licensee and she understands that she must be home during day care hours at least 80% of the time every day and ensure that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

LPA printed and provided licensee with the following documents: Parent's Rights Pub, LIC999 - Facility Sketch, LIC9040 - Facility Roster.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

As a result of today's inspection Type A and Type B citations have been issued. More information available on the attached LIC809-D pages. LPA informed licensee Stephanie Antoni that this report dated 11/12/2024 documents 2 - Type A citations which shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
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Document Has Been Signed on 11/12/2024 12:23 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 11/12/2024 at 10:45 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: ANTONI, STEPHANIE
FACILITY NUMBER: 434412947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 Children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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Licensee to provide photographic proof that immunization records have been collected for all children in care and transfer the records to the PM286. This should be completed by 11/13/24 or by the next time child is in care.
Type A
Section Cited
HSC
1597.622(a)(1)
(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 record review and interview, the licensee did not comply with the section cited above in 1 out of 1 employee files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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Licensee to send photographic proof of employee immunization records, Negative TB test and flu vaccination or declination.
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:Joel Segura
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


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Document Has Been Signed on 11/12/2024 12:23 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 11/12/2024 at 10:45 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: ANTONI, STEPHANIE
FACILITY NUMBER: 434412947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observations, the licensee did not comply with the section cited above in 2 out of 4 areas which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee to clean bathroom removing dust, debris, cobwebs or insects. Licensee to clean all outdoor toy and bikes to remove layers of dust and debris. Licensee to provide photographic evidence to LPA.
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 observations, the licensee did not comply with the section cited above regarding a fire extinguisher that meets standards established by the State Fire Marshal which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee to service fire extinghisher or replace with a new fire extinguisher. LIcensee to get fire extinguisher serviced each year or replace the unit.
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:Joel Segura
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2024 12:23 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 11/12/2024 at 10:45 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: ANTONI, STEPHANIE
FACILITY NUMBER: 434412947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and interview, the licensee did not have required postings at entrance, this does not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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Licensee will post required postings and provide photographic evidence to the LPA.
Type B
Section Cited
HSC
1596.8662(b)(1)
(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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 staff people, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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All staff people will complete Mandated Reporter training and provide a copy of the certificate to LPA.
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:Joel Segura
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


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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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ANTONI, STEPHANIE
FACILITY NUMBER: 434412947
VISIT DATE: 11/12/2024
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Also, LPA informed the licensee to provide a copy of this licensing report dated 11/12/2024 that documents any Type A citations 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.

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.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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