434414297-10-12-2022-07-CC-SYIP-CK626S-20221012170736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414297
Report Date: 10/12/2022
Date Signed: 10/12/2022 05:08:13 PM

Document Has Been Signed on 10/12/2022 05:08 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:	JOHNSON, CHRISTINA		FACILITY NUMBER:	434414297
ADMINISTRATOR:	JOHNSON, CHRISTINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 413-9272
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 1	DATE:	10/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Christina Johnson		TIME COMPLETED:	12:30 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) Samantha Yip conducted an unannounced Required 1- Year inspection. LPA met with Licensee Christina Johnson and explained the reason for the inspection. Present during the inspection were Licensee and one child, whom was infant age. Licensee is also a resource family home. License and notification of parent's rights were observed to be posted. The hours of operation are Monday through Friday 6AM to 6PM. There is a working phone in the home. LPA toured the inside and outside of the home with Licensee. There are stairs in the home, which are barricaded. The fireplace in the home is barricaded. The off-limit areas of the home are the garage and the entire upstairs. Disinfectant, cleaning supplies, and other items that are dangerous to children were inaccessible. Toys and equipment were observed to be age-appropriate. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 04/2022. LPA reminded Licensee that fire/disaster drill need to be conducted every 6 months. Licensee stated that there are no weapons, such as firearms, stored in the home. The backyard is used and is fenced. There is a pool in the backyard, which is fenced and the gate was locked. Equipment for children were observed to be in good conditions. There were no other bodies of water observed during today's inspection. -------------------continues on 809 dated 10/12/2022 page 2----------------------

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: JOHNSON, CHRISTINA	FACILITY NUMBER: 434414297
	VISIT DATE: 10/12/2022

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
26
27
28
29
30
31
32

----------------continuation of 809 dated 10/12/2022 page 1-----------------------

There are play yards in the home. LPA reminded Licensee to ensure that sheets are tight-fitted. Licensee checks infant every 15 minutes while napping and documents it on their daily sheet, which is sent home. LPA discussed with Licensee that she needs to keep a copy of the log. Licensee will send a copy of log to Licensing. 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. 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.

Licensee does not provide Incidental Medical Services (IMS). 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: http://www.ada.gov/childqanda.htm

Licensee does transport children and understands that children cannot be left unattended in parked vehicles.

A copy of the facility roster was obtained during today's inspection. One child's file was reviewed during today's inspection. The records reviewed include but not limited to immunization records and parent's rights. LPA discussed with Licensee to ensure that form is filled out completely. LPA observed that the LIC 700 was not signed for C-1 and name was not filled out on parent's rights.
-------------------continues on 809 dated 10/12/2022 page 3-----------------------

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: JOHNSON, CHRISTINA	FACILITY NUMBER: 434414297
	VISIT DATE: 10/12/2022

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
26
27
28
29
30
31
32

------------------continuation of 809 dated 10/12/2022 page 2---------------------

Licensee completed the Mandated Reporter training on 08/2022. Licensee is a certificated CPR/1st Aid Instructor through HSI, which is valid until 07/19/2023. Licensee will submit a copy of immunization record for measles.

Licensee is the only adult living the home. Licensee also has three minor children. Licensee has a cleared fingerprints or exemption. Licensee 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.

An updated LIC 279, LIC 279B, and proof of property were obtained during today's inspection.

Licensee will submit:
- sleep log for C-1
- immunization record for measles

As a result of this inspection, a technical violation was issued. Exit interview conducted and report was reviewed with Licensee Christina Johnson. 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.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4