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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415507
Report Date: 05/17/2024
Date Signed: 05/17/2024 09:58:57 PM

Document Has Been Signed on 05/17/2024 09:58 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:CEBALLOS, ELISFACILITY NUMBER:
434415507
ADMINISTRATOR/
DIRECTOR:		CEBALLOS, ELISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 561-4561
CITY:SAN JOSESTATE: CAZIP CODE:
95110
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
05/17/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:32 PM
MET WITH:Elis CeballosTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Samantha Yip and Jennifer Beehler conducted an unannounced Annual/Random inspection. LPA met with Licensee Elis Ceballos and explained the reason for the inspection. Present during today's inspection were Licensee, her assistant, and seven children, whom two were infant age.

There is a board to post required posting, such as license and notification of parent's rights. The hours of operation are Monday through Friday 6AM to 6PM. Licensee uses her cell phone.

LPAs toured the inside and outside of the home with Licensee. The off-limit areas of the home are the two bedrooms and bathroom in the main home and the basement. Disinfectant, cleaning supplies, and other items that could pose a risk to children were inaccessible. LPA discussed with Licensee about any grater, peelers, or blenders need to be inaccessible. There are toys and equipment for children. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 04/05/2024. Licensee stated that there are no weapons, such as firearms, stored on the premise. Licensee does have a pet.

The outside area is fenced. The off-limit areas outside are the shed, left and right side of the yard. There were no bodies of water observed during today's inspection. LPA discussed with Licensee about making sure any equipment, such as picnic table is in functioning condition.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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 6
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: CEBALLOS, ELIS
FACILITY NUMBER: 434415507
VISIT DATE: 05/17/2024
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------------------continuation of 809 dated 05/17/2024 page 1---------------------

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 [or facility representative] 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. LPA discussed with Licensee about putting the whole time on the sleep check and to make sure they are documenting the time.

This facility provides Incidental Medical Services – IMS. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

A copy of the facility was obtained. Four children's files were reviewed during today's inspection. The records reviewed include but not limited to parent's rights. LPA discussed with Licensee that immunization records need to be on PM 286.

Licensee and assistant's files were reviewed. The records reviewed include but not limited to immunization records and Mandated Reporter training. Licensee and her assistant have valid CPR/1st Aid. Licensee's CPR/1st Aid expires on 02/11/2025. LPA discussed with Licensee about ensuring that assistant have all the paperwork on file.
------------------continuation of 809 dated 05/17/2024 page 3--------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: CEBALLOS, ELIS
FACILITY NUMBER: 434415507
VISIT DATE: 05/17/2024
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-----------------continuation of 809 dated 05/17/2024 page 2------------------

The adults 18 and over living in the home are Licensee. Licensee has cleared criminal record, child abuse, or exemption, and TB test. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During the exit interview, the LICENSEE Elis Ceballos, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

An updated LIC 279 and LIC 279B was obtained during today's inspection; along with proof of property.

Licensee will submit the following:
- LIC 9227: Section D signed by parent for C-1
- LIC 627 and LIC 995A for C-2

As a result of this inspection, no deficiencies were issued. Exit interview conducted and report was reviewed with Licensee Elis Ceballos. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
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