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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413431
Report Date: 09/28/2021
Date Signed: 09/28/2021 04:42:41 PM

Document Has Been Signed on 09/28/2021 04:42 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:ZAMUDIO, MICHAELFACILITY NUMBER:
434413431
ADMINISTRATOR:ZAMUDIO, MICHAELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 227-0640
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Michael ZamudioTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Michael Zamudio for a required one year visit. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's wife, adult niece Lynette, adult nephew Moses Espinosa and five day care children. Lynette is licensee's assistant. Days and hours of operation are Monday to Friday, 6:30am to 5:30pm. The adults that reside in the home are licensee and his wife.

A review of staff records on 09/27/2021 indicates that not all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Moses Espinosa does not have criminal record clearance. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately remove the individual and prevents them from returning to the home or having contact with children in care.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed a barricaded fireplace in the home. LPA did not observe required posting on the wall. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed cleaning products under kitchen sink, a knife on a table on an outside table, a large skill saw in the backyard, an unlocked backyard storage with lawn and garden chemicals accessible to children. Off limits bedrooms doors were open. LPA observed vitamins, medications and scissors accessible to children. LPA did not observed a fire extinguisher. LPA observed a working smoke detector. LPA did not observe carbon monoxide detector. LPA observed two guns in off limits rooms that were locked. Ammunition was stored separately. Off limit areas indoor: master bedroom/bath, two bedrooms and attached garage. There are no bodies of water. Backyard is fenced. Off limits outdoor: left side of home that is fenced off to children. Licensee states he has three dogs and are vaccinated. LPA observed licensee and his wife have a current CPR and First Aid certification expiring 07/23/2022. Licensee and his
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431
VISIT DATE: 09/28/2021
NARRATIVE
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wife completed Mandated Reporter training on 07/27/2018. Assistant Lynette has not complete training.

LPA did not observe a current roster of the children. LPA observed a fire and disaster drill log which was last completed on 09/09/2021. LPA reviewed three children's files and observed all forms are completed and children have current immunization records. Child 4 and 5 do not have files. Licensee states day care is not insured. LPA observed LIC282 in children's files. LPA discussed SB792 Immunization Requirements and observed licensee and wife have immunization records on file. LPA observed assistant Lynette did not have a file. Lynette did not have immunization.

Supervision of children was discussed with licensee and he understands that he must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands his capacity options and he understands that he cannot have more than 14 children in the home at any time. Licensee understands if he transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

Safe sleep update: LPA discussed the new “Safe Sleep” regulations with the Licensee including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee. LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, and all infants shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.

LPA discussed Zero Tolerance related regulations with licensee Michael Zamudio and was advised of the assessment of $500 immediate civil penalty and an ongoing $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee Michael and provided him the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements. Upon receipt, licensee Michael shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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Document Has Been Signed on 09/28/2021 04:42 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 09/28/2021 at 03:11 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: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2021
Section Cited
CCR
102370(d)(1)

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All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the Department.
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Licensee shall ensure all adults are cleared prior to being in the home around children. Licensee will have Moses cleared prior to allowing him to enter the home during day care hours.
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This requirement was not met as evidenced by Moses Espinosa does not have criminal record clearance. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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Type A
09/29/2021
Section Cited
CCR102417(g)(4)

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Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement was not met as evidenced by LPA observed cleaning products under kitchen
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Licensee removed the knife in the backyard, the cleaning supplies under the sink and locked the storage during visit. Licensee will submit photos of removed skill saw.
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sink, a knife on a table on an outside table, a large skill saw in the backyard, an unlocked backyard storage with lawn and garden chemicals accessible to children. Off limits bedrooms doors were open. LPA observed vitamins, medications and scissors accessible to children. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
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:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021


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Document Has Been Signed on 09/28/2021 04:42 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 09/28/2021 at 03:22 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: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2021
Section Cited
CCR
102417(g)(1)

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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 Marshal.
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Licensee will submit a photo of a fully charged 2A10BC or larger fire extinguisher to CCLD by 09/29/2021.
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This requirement was not met as evidenced by LPA did not observed a fire extinguisher. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
09/29/2021
Section Cited
HSC1597.543

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Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
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Licensee will submit photos of a working carbon monoxide detector to CCLD by 09/29/2021.
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This requirement was not met as evidenced by LPA did not observe carbon monoxide detector.. This poses a potential risk Health, Safety Personal Rights risk to 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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021


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Document Has Been Signed on 09/28/2021 04:42 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 09/28/2021 at 03:50 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: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2021
Section Cited
CCR
102417(g)(7)

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An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
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Licensee will submit file for child 4 and 5 to CCLD by 10/12/2021.
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This requirement was not met as evidenced by Child 4 and 5 do not have files. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
10/12/2021
Section Cited
CCR102419(d)(1)

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The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A.
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Licensee will submit file for child 4 and 5 to CCLD by 10/12/2021.
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This requirement was not met as evidenced by Child 4 and 5 do not have files. This poses a potential risk Health, Safety Personal Rights risk to 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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021


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Document Has Been Signed on 09/28/2021 04:42 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 09/28/2021 at 03:56 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: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2021
Section Cited
CCR
102418(g)

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102418(g) Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
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Licensee will submit file for child 4 and 5 to CCLD by 10/12/2021.
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This requirement was not met as evidenced by Child 4 and 5 do not have files. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
09/29/2021
Section Cited
CCR102419(b)

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The Licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in an accessible area in the family child care home at all times children are in care.
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Licensee posted during visit. Deficiency cleared today.
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This requirement was not met as evidenced by LPA did not observe required posting on the wall. This poses a potential risk Health, Safety Personal Rights risk to 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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021


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Document Has Been Signed on 09/28/2021 04:42 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 09/28/2021 at 04:00 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: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2021
Section Cited
HSC
1596.8662(b)(1)

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1596.8662(b)(1) 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 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.
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Licensee, his wife and Lynette will complete mandated reporter training and submit certificate to CCLD by 10/12/2021.
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This requirement was not met as evidenced by wife completed Mandated Reporter training on 07/27/2018. Assistant Lynette has not complete training. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
10/12/2021
Section Cited
CCR102369(9)

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Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.
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Licensee will submit a current TB test for Lynette by 10/12/2021.
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This requirement was not met as evidenced by LPA observed assistant Lynette did not have a file. This poses a potential risk Health, Safety Personal Rights risk to 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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021


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Page: 7 of 9
Document Has Been Signed on 09/28/2021 04:42 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 09/28/2021 at 04:07 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: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2021
Section Cited
CCR
102417(8)

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met as evidenced by LPA did not observe a current roster of
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Licensee will complete roster and submit a copy to CCLD by 10/12/2021.
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the children. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
10/12/2021
Section Cited
HSC1597.622(a)(1)

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1597.622 (a) (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.
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Licensee will submit immunizations for Lynette to CCLD by 10/12/2021.
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This requirement was not met as evidenced by Lynette did not have immunization. This poses a potential risk Health, Safety Personal Rights risk to 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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021


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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: ZAMUDIO, MICHAEL
FACILITY NUMBER: 434413431
VISIT DATE: 09/28/2021
NARRATIVE
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The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. LPA reminded Michael that mask are required for adults and all children 2 and above when indoors.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
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