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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415131
Report Date: 10/29/2021
Date Signed: 11/09/2021 02:29:35 PM

Document Has Been Signed on 11/09/2021 02:29 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:MARTINEZ, AISHAFACILITY NUMBER:
434415131
ADMINISTRATOR:MARTINEZ, AISHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 621-3939
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Lucia Olivera and Aisha MartinezTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee's assistant, Lucia Olivera. Lucia states that Licensee, Aisha Martinez stepped out to pick up pizza for the children for their Halloween celebration. LPA observed one infant, 5 pre-schoolers and Licensee's 4 year old son present during the inspection. LPA explained the nature of today's inspection to Lucia. Licensee arrived at 12:28 PM. Adults living in the home are Licensee and her parents. Days and hours of operation are Monday to Friday, 6:30 AM to 5:00 PM.

LPA toured the indoor and outdoor of the home. LPA observed a blocked fireplace and no wall heaters. Off limits indoor: master bedroom, master bathroom, two bedrooms, and the garage. There is a fountain in the front yard; no water is in the fountain. LPA request that Licensee fill the fountain with dirt/plants or rocks. Licensee stated there is no firearms/weapons in the home. Licensee understands that sharp objects, medicines, poisons and cleaning supplies should be inaccessible to the children. Backyard is fenced. LPA observed a barricaded storage shed which is inaccessible to children. Off limits outdoor: both side yards. LPA reminded licensee that she can only have 14 children according to her license with a qualified assistant.

LPA observed a 2A10BC fire extinguisher. Smoke and carbon monoxide detectors were tested and proved to be functioning. Home is clean and orderly with heating and ventilation for safety and comfort. LPA observed sufficient materials, toys, and play equipment for the day care children. Telephone is in working order. Children were supervised during the inspection. LPA also discussed if Licensee transports children, they are never to be left in parked vehicles.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 10/29/2021 was reviewed; and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions.

LPA reviewed facility roster. LPA reviewed six children's files and 1 staff file.

Facility Evaluation Report dated 10/29/2021 to be continued on next page:
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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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: MARTINEZ, AISHA
FACILITY NUMBER: 434415131
VISIT DATE: 10/29/2021
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Facility Evaluation Report dated 10/29/2021 to be continued from previous page:

Licensee's CPR and first aid expires on 07/17/2023 and her Assistant/mother (Lucia) CPR expires on 07/17/2023. Licensee completed Mandated Reporter Training on March 19, 2021. Assistant (Lucia) completed her Mandated Reporter Training on March 19, 2021. Licensee understands that she is to complete the Mandated Reporter training every two years. LPA reviewed assistants file. File is complete. Measles and Pertussis vaccines are on file.

LPA discussed the immediate civil penalties for Zero Tolerance of $500, and an ongoing $100 per day per violation until the violation(s) is corrected. The Healthy Beverage Act and AB633 requirements for type A violation were also discussed. 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.



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

Licensee's email address is AishaMTZV@yahoo.com
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/09/2021 02:29 PM - It Cannot Be Edited


Created By: Elizabeth Berumen On 10/29/2021 at 01:55 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: MARTINEZ, AISHA
FACILITY NUMBER: 434415131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 one infant did not have the LIC 9227 in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee agrees to complete the LIC 9227 and email or mail a completed copy to LPA by Plan od correction date of 11/05/2021.
Type B
Section Cited
CCR
102425(j)(2)(D)
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:

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. Licensee did not have a 15 check for infant logged in infants file.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee agrees to email or mail a log where she indicates the 15 minute sleep checks.
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:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/09/2021 02:29 PM - It Cannot Be Edited


Created By: Elizabeth Berumen On 10/29/2021 at 01:55 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: MARTINEZ, AISHA
FACILITY NUMBER: 434415131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2021

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 record review the licensee did not comply with the section cited above. Infant file did not contain the sleep checks which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee agrees to email or mail a log where she indicates the 15 minute sleep checks.
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:Mary Segura
LICENSING EVALUATOR NAME:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2021


LIC809 (FAS) - (06/04)
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