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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412947
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:51:16 PM

Document Has Been Signed on 11/15/2024 12:51 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
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: 7DATE:
11/15/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Staff 1 & Staff 2TIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Jennifer Beehler met with Staff #1 (S1) and Staff #2 (S2) to complete a plan of correction inspection as a follow up to the Annual Visit completed on 11/12/2024. LPA was provided access to the facility by the two helpers and stated the reason for the visit, to review plan of correction items.

LPA observed 7 children in care with two helpers. The licensee was not present. LPA asked when licensee had left, staff stated recently. LPA asked staff if she was available for the inspection. Staff contacted licensee and licensee advised she was unavailable as she was in a meeting. LPA asked S1 if licensee could join us for the report review over the phone. S1 stated she didn't know if she was available because she didn't know when her meeting ended.

LPA did not receive any immunization records since the Annual Visit and licensee has not reached out for an extension. LPA did receive an email with a handwritten letter from S1 stating her immunization records were not currently available dated 11/14/2024. LPA questioned S1 about her immunity records. S1 stated they were at her parents and she doesn't have access to them. LPA observed the postings at the entrance, including the report from 11/12/2024. LPA could not verify any staff or children's records as S1 & S2 stated records are in the home and they do not have access to the home. LPA could not review files for LIC9224, so it is unsure if parents have been presented with the report. LPA did not observe any of the other items addressed at this time.LPA stated that she has referred licensee to a resource and referral agency (R&R) to assist in record keeping and facility regulations. LPA left a pamphlet for more information. Someone from the R&R will be reaching out to assist the licensee with compliance. LPA reminded staff that until the two (2) Type A citations are addressed a Civil Penalty of $100/ Per Day X 2 citations will be assessed until compliance has been made.

Due to today's inspection, two (2) civil penalties have been assessed on the attached LIC421FC. Exit interview, conducted with S1, report was reviewed and provided along with appeal rights. A NOTICE OF SITE VISIT WAS PROVIDED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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