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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415413
Report Date: 06/13/2023
Date Signed: 06/13/2023 05:46:06 PM

Document Has Been Signed on 06/13/2023 05:46 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:FURTADO, ANAFACILITY NUMBER:
434415413
ADMINISTRATOR:ANA FURTADOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 826-2179
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 14TOTAL ENROLLED CHILDREN: 15CENSUS: 13DATE:
06/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Ana FurtadoTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kassandra Medrano conducted an annual required inspection which included a toured the home and yard, and a review of the required day-care forms with the licensee today. Present in the home is Licensee, 13 children and 2 adult assistants, Maria Rodriguez, and Alejandra Reyes, as well as 2 minor . Capacity and ratio requirements of children were observed in compliance today. OFF LIMIT AREAS: garage, bedroom 1, bathroom 2, Master Bedroom, office Adults living in the home are Licensee, and husband, Bret Furtado, and infant. A review of records indicates that all adults working or living in the home 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. The day-care operates 7:30am-5:30pm. LPA observed the following: Upon inspection of outdoor area it was observed multiple different types of cleaning products that should be kept inaccessible to children within reach. No baby walkers, bouncers, exercausers, etc. allowed to be used during day-care hours. Home has proper lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher. Licensee stated that there is a body of water on property, LPA observed that hot tub was properly barricaded. Licensee states there are no guns or weapons of any kind in the home. During review of files, Licensee’s CPR and First Aid expired 3/2023. Emergency drills have not conducted within the last year. Licensee provides daily snacks and lunch is provided by parents. Isolation of sick children reviewed/discussed. During review of records it was observed that Children’s roster was not current. During file review it was observed that children's files were incomplete or missing. As well as staff files which were missing documents, such as mandated reporter. Supervision and transportation of children was discussed. Capacity options were reviewed. Licensee understands that care cannot be provided for more than the capacity as stated on the license. Requirements for reporting suspected child abuse was discussed, as well as reporting requirements for unusual incidences.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: FURTADO, ANA
FACILITY NUMBER: 434415413
VISIT DATE: 06/13/2023
NARRATIVE
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 All required postings are properly posted (License/Parent’s Rights poster/Emergency Disaster Plan and Earthquake Preparedness Checklist) Licensee has updated immunization's. Licensee was reminded that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and1597.662. Licensee was informed about the Provider Information Notices (PINs) on CCLD website. Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com). 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. This report and appeal rights were discussed with Licensee. This report must be available in the
facility for public review. 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.


California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):

"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS. LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH APPLICANT/PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.

Exit interview conducted and report was reviewed with the licensee, Ana.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 06/13/2023 05:46 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 06/13/2023 at 04:56 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: FURTADO, ANA
FACILITY NUMBER: 434415413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed bleach, comet and lysol cans accesible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2023
Plan of Correction
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Licensee immediately moved cleaning compounds to inaccesible areas.
Type A
Section Cited
CCR
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, pursuant to Health and Safety Code Section 1596.866.

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, licensees CPR expired 3/2023 and no one else in the facility had current CPR which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2023
Plan of Correction
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Licensee to send documentation of enrollment, and send completion of training.
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:Diana Stephenson
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 06/13/2023 05:46 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 06/13/2023 at 04:56 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: FURTADO, ANA
FACILITY NUMBER: 434415413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

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, the last drill that was conducted was 3/2022 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Licensee to send documention of emergency drill
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 interview and record review, the licensee did not comply with the section cited above in 3/3 staff were missing current training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Licensee to send certificates via email.
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:Diana Stephenson
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 06/13/2023 05:46 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 06/13/2023 at 04:56 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: FURTADO, ANA
FACILITY NUMBER: 434415413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

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 2/15 were missing files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Licensee to send documentation of the two childrens files.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

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 that she did not keep the childrens roster current which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Licensee to send a copy of roster once it is complete
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:Diana Stephenson
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 06/13/2023 05:46 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 06/13/2023 at 04:56 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: FURTADO, ANA
FACILITY NUMBER: 434415413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023

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, the 1 infant enrolled does not have form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Complete form and email to LPA for the one infant 12 months and younger.
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 onrecord review, the licensee did not comply with the section cited above in which the 2 infants enrolled do not have sleeping logs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Licensee to send documentation of completion of infant sleeping logs.
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:Diana Stephenson
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023


LIC809 (FAS) - (06/04)
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