<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414297
Report Date: 06/28/2024
Date Signed: 06/28/2024 04:36:19 PM

Document Has Been Signed on 06/28/2024 04:36 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: 5DATE:
06/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Catalinda RetanaTIME VISIT/
INSPECTION COMPLETED:
04:45 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
On 6/28/24, at 3:15 PM, Licensing Program Analyst (LPA), Doni Fici, arrived unannounced to conduct a Case Management visit. LPA was greeted by Catalinda Retana, Staff and explained the purpose of the visit.

During visit, LPA was greeted by staff and was allowed into the home. During the time of the visit, LPA was informed that the Licensee left the home today, 6/28/24, at approximately 7 AM and has not returned to the day care. On 6/7/24, LPA informed the Licensee that she is not able to leave the home for more than 20 percent of the time (2 hours). LPA observed two (2) staff members; an 18 years old (S1), and 15 years old (S2). LPA attempted to conduct a file review of the children's files, however, staff do not know where they are at. LPA asked S1 about her first aid/ CPR and mandated reporters training and staff stated she did not complete the training and is working in the home without any current certificates. LPA asked S1 when did she start and S1 stated June 11, 2024.

LPA toured the home and seen the backyard pool gate open and accessible to children in care; there are 2 dogs in the backyard.

A civil penalty of $500 is being assessed during today's visit.

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.


Continue on Page Lic809-C...
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2024
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
Document Has Been Signed on 09/04/2024 03:01 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/19/2024 03:32 PM


Created By: Liridon Fici On 06/28/2024 at 03:47 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JOHNSON, CHRISTINA
FACILITY NUMBER: 434414297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2024
Section Cited
CCR
102417(a)

1
2
3
4
5
6
7
102417(a)- Operation of a Family Child Care Home (a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit a self-certification on section 102417(a)- Operation of a Family Child Care Home of a signed and dated plan on how will you ensure to be present at the day care for 80 percent of the time during hours of operation to CCL by POC due date.
8
9
10
11
12
13
14
Based on interviews, the licensee did not comply with the section cited above by leaving the day care for more than 20 percent of the time which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
06/29/2024
Section Cited
CCR102417(g)(5)

1
2
3
4
5
6
7
102417(g)(5)- Operation of a Family Child Care Home. (g) The home shall be free from defects or conditions which might endanger a child... (5) All licensees shall ensure the inaccessibility of pools... and similar bodies of water...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit a self-certification on section 102417(g)(5)- Operation of a Family Child Care Home, of a signed and dated plan on how will you ensure this will not be repeated and how to understand the dangers of accessible pools and to submit to CCL by POC due date.
8
9
10
11
12
13
14
Based on observation and record review, the licensee did not comply with the section cited above by allowing the pool gate to be accessible to children which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 06/28/2024
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
Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to the parent of children enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file.

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: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/08/2024 02:19 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/25/2024 01:23 PM


Created By: Liridon Fici On 06/28/2024 at 04:12 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JOHNSON, CHRISTINA
FACILITY NUMBER: 434414297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
102416(c)

1
2
3
4
5
6
7
102416(c) Personnel Requirements: (c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to have S1 complete her first aid/CPR training and to submit proof of completed training to CCL by POC due date.
8
9
10
11
12
13
14
Based on observation and record review, the licensee did not comply with the section cited above by not having current first aid/CPR training for S1 which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
07/05/2024
Section Cited
HSC1596.8662(b)(1)

1
2
3
4
5
6
7
1596.8662(b)(1) Mandated Reporter
(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...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will have S1 complete her mandated reporters training and to submit proof to CCL by POC due date.
8
9
10
11
12
13
14
Based on observation and record review, the licensee did not comply with the section cited above by not having S1 complete her required mandated reporter training which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4