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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414757
Report Date: 10/12/2022
Date Signed: 10/14/2022 10:55:33 AM

Document Has Been Signed on 10/14/2022 10:55 AM - 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PERALES, GRACIELA VARGASFACILITY NUMBER:
434414757
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Graciela VargasTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analysts Anna Morales conducted an ANNUAL REQUIRED visit and was greeted by Licensee Graciela Perales and one staff. Also present were seven children ( two infants under two years old, four preschool aged children and one school aged chid child). LPA observed a current child roster. Last disaster drill was conducted on 9/2/22

Children were playing under the supervision of the Licensee and one staff. Days and hours of operation are Monday - Friday from 6:30 AM -5:30 PM. The licensee is the only Adult residing in the home and she has a Criminal Background Check Clearance, signed Criminal Record Statements LIC508 on file with Licensing Office.

LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA observed a wall heaters inside the home which is covered/barricaded in the living room. Off limit areas in the home are the two bedrooms. There are no stairs inside the home. Off limit areas outside the home: a portion of the left side section of the backyard.

LPA observed a fully charged fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water. The Licensee has one dog which does not interact with the children. Licensee stated that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children.
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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
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.

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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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PERALES, GRACIELA VARGAS
FACILITY NUMBER: 434414757
VISIT DATE: 10/12/2022
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. Licensees stated that she does not take care of any children who are ill. 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. Licensee have an area where sick children can be isolated from the others until parent pick-up.
Licensees Mandated Reporter Training current (AB1207), however, S2 does not.. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

A random selection of children’s files were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization Records (PM286).

Licensee file were reviewed for the following records: Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). LPA observed that S2 does not have a complete file and was unable to observe the documents stated above. Licensee does have a current First Aid/CPR on file and it expires on 9/24/2024.

LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
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
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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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PERALES, GRACIELA VARGAS
FACILITY NUMBER: 434414757
VISIT DATE: 10/12/2022
NARRATIVE
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LPA discussed and left a copy of Pin 20-24-CCP, RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT. Discussed that all INFANTS UP TO 12 MONTHS OF AGE MUST HAVE AN INDIVIDUAL INFANT SLEEPING PLAN (LIC9227) ON FILE, WHICH WILL DOCUMENT THE INFANTS SLEEPING HABITS, USUAL SLEEPING ENVIRONMENT, AND THE INFANT ROLLING ABILITIES. PROVIDERS MUST CONDUCT CHECKS AND DOCUMENT EVERY 15 MINUTES ON SLEEPING INFANTS (UP TO TWO YEARS OLD). 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.

LPA discussed the requirements of AB 633 with the Licensee and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Exit Interview was conducted with Licensee. Deficiencies are being cited based on the LPA's observations, interviews conducted and records reviewed in accordance with the California Code of Regulations Title 22.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.

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/inspection-process
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
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
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Document Has Been Signed on 10/14/2022 10:55 AM - It Cannot Be Edited


Created By: Anna Morales On 10/12/2022 at 11:59 AM
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: PERALES, GRACIELA VARGAS
FACILITY NUMBER: 434414757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

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 documenting C3 and C5, 15 minute check while they were sleeping, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2022
Plan of Correction
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Licensee stated that she will submit the sleep check documentation to CCL by the POC date.
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. S2 did not have a Mandated Reporter Training on file which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 11/11/2022
Plan of Correction
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Licensee stated that she will submit the Mandated ReporterTraining by the POC 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:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022


LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 10/14/2022 10:55 AM - It Cannot Be Edited


Created By: Anna Morales On 10/12/2022 at 11:59 AM
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: PERALES, GRACIELA VARGAS
FACILITY NUMBER: 434414757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

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 in S2. LPA Morales was unable to review S2 personnel file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2022
Plan of Correction
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Licensee stated that she will submit Personnel records for S2 by the POC 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 record review, the licensee did not comply with the section cited above.C3 who is under twelve months old does not have a Individual Infant Sleeping Plan (LIC9227) in file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2022
Plan of Correction
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Licensee stated that she will submit the Individual Infant Sleeping Plan (LIC9227) by the POC date, October 26,2022.
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:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022


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