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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414297
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:40:04 PM

Document Has Been Signed on 05/10/2024 03:40 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:JOHNSON, CHRISTINAFACILITY NUMBER:
434414297
ADMINISTRATOR/
DIRECTOR:		JOHNSON, CHRISTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 413-9272
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
05/10/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Partida, AngelciaTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On 5/10/2024, at 12:00 PM, Licensing Program Analyst (LPA) Doni Fici arrived unannounced to conduct a Required 1-Year inspection and was greeted by Staff, Partida, Angelcia, and explained the purpose of the visit. Staff called the Licensee and Licensee stated to LPA that she is out of town for the day and is allowing Staff to sign report on her behalf.

Days and hours of operation are Monday through Friday from 7:00 AM to 7:00 PM. Staff stated that the licensee is the only adult residing in the home. Upon entrance, LPA observed two (2) staff and nine (9) children in care during inspection. Licensee certifications for CPR and First Aid is current and will expire on 7/19/24.



LPA toured the indoor and outside areas of the home with licensee during today's inspection. LPA obtained a copy of the Child Care Facility Roster during today's inspection, and it is current. LPA reviewed five (5) child's file and observed that parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification and emergency information forms are in each file. LPA review two (2) staff files and observed all forms/documentation's are current. LPA observed that last fire drill was documented on 10/12/2023.

The Licensee has a working cell phone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. LPA observed there are stairs in the home leading to the second floor. Off limit areas in the home is the kitchen, living room, upstairs, and garage. Licensee uses part of the back yard as a playground. Off limits areas to the outside of the house is the swimming pool, and sides of the house.

LPA observed a fully charged 3A4BC fire extinguisher, with working smoke and carbon monoxide detectors. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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Document Has Been Signed on 05/10/2024 03:40 PM - It Cannot Be Edited


Created By: Liridon Fici On 05/10/2024 at 02:59 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: JOHNSON, CHRISTINA
FACILITY NUMBER: 434414297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(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:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not completing the required mandate reporting training for S1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Licensee agreed to complete the required mandated reporting training for S2 and to submit proof of certificate to CCL by POC due date.
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
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Based on interview and record review, the licensee did not comply with the section cited above in not maintaining an individualize infant sleep plan (Lic9227) for C1, C2, and C3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Licensee agreed to complete an Lic9227: individualize infant sleep plan for C1, C2, and C3 and to submit a copy of proof to CCL by POC due date.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/10/2024 03:40 PM - It Cannot Be Edited


Created By: Liridon Fici On 05/10/2024 at 02:59 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: JOHNSON, CHRISTINA
FACILITY NUMBER: 434414297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not conducting and logging in 15 minute sleep checks for Child 1, child 2, and child 3 (C1,C2, and C3), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Licensee agreed to conduct infant sleep check every 15 minutes and to submit proof of logs for C1, C2, and C3 to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: JOHNSON, CHRISTINA
FACILITY NUMBER: 434414297
VISIT DATE: 05/10/2024
NARRATIVE
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LPA observed Licensee has proof of immunization for pertussis, measles, and influenza in her file for herself according with the SB792.
Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time and a helper must be present. The Licensee states that she does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.

Department website: www.ccld.ca.gov provided to Licensee.

LPA discussed the requirements of AB 633 with the Licensee. LPA also discussed "zero tolerance" related regulations with the Licensee. Licensee has completed the required "mandated reporter" training on 11/8/2023. Licensee understands that all adults in contact with children are required to complete the training. LPA provided licensee with the website address for the training: www.mandatedreporterca.com for additional information.

A review of staff records on 5/10/2024 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 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.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: JOHNSON, CHRISTINA
FACILITY NUMBER: 434414297
VISIT DATE: 05/10/2024
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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.

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. Licensee currently has no kids that need IMS assistance. Staff stated there are no children currently using any IMS.

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.

The following type B deficiency was cited on the attached page (809-D). Licensee was informed that failure to correct the deficiency 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.



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

Exit interview conducted with staff, and a copy of this report reviewed and provided along with appeal rights.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
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