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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415579
Report Date: 11/16/2021
Date Signed: 11/19/2021 04:21:22 PM

Document Has Been Signed on 11/19/2021 04:21 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:GARCIA CONTRERAS, LOURDESFACILITY NUMBER:
434415579
ADMINISTRATOR:LOURDES GARCIA CONTRERASFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 583-7871
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lourdes Garcia ContrerasTIME COMPLETED:
04:45 PM
NARRATIVE
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On 11/16/2021 at 1:30 PM, Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee, Lourdes Garcia Contreras for a 1 year required inspection. LPA explained the reason for the visit to Licensee. Present during today's inspection were licensee and 7 day care children. LPA observed 4 infants and 3 preschoolers present with Licensee. Licensee states that her assistant, Maria Ibarra Huerta is on lunch. Adults living in the home are licensee and her boyfriend (Alejandro Rivera Zaragoza). LPA explained to Licensee that when an assistant is not present at a large family child care home, then the licensee shall comply with the capacity requirement for a small license. Licensee was operating out of ratio. Licensee's assistant arrived at 2:36 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 11/16/21 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. 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.

LPA observed a cpr & first aid certification for Aurelia Vega Vargas; LPA informed Licensee that Aurelia is not associated or cleared to be in the family child care home.

LPA inspected inside and outside of the home. There are no stairs in the home. LPA observed a screened and barricaded fireplace. Off limit areas inside the home: master bedroom, master bathroom, one bedroom, part of dining room adjacent to kitchen, laundry area, and the garage. Today, LPA observed an infant napping in off limit bedroom; infant was asleep on the couch that is in the bedroom. Today, the kitchen and dining room area was not barricaded by anything and is accessible to children. LPA observed a fully charged 2A10BC fire extinguisher, working smoke detector and carbon monoxide detector, fenced backyard, and no bodies of water. Off limit areas outdoor: barricaded right side yard. Applicant states that there are no weapons in the home. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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: GARCIA CONTRERAS, LOURDES
FACILITY NUMBER: 434415579
VISIT DATE: 11/16/2021
NARRATIVE
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Supervision of children was discussed with Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time with a qualified assistant. Licensee states that does not transport any day care children. Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Licensee has current CPR & First aid expiring on 08/16/22. Licensee has immunization against pertussis and measles.

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/process

Deficiencies were cited on 809D.

NOTICE OF SITE VISIT WAS ISSUED AND SHALL BE POSTED FOR 30 DAYS ALONG WITH TYPE A DEFICIENCY.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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Page: 4 of 9
Document Has Been Signed on 11/19/2021 04:21 PM - It Cannot Be Edited


Created By: Elizabeth Berumen On 11/16/2021 at 03:58 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: GARCIA CONTRERAS, LOURDES
FACILITY NUMBER: 434415579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(e)
Infant Safe Sleep
No infant shall be forced to sleep, to stay awake, or to stay in the designated sleeping area.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interview, the licensee did not comply with the section cited above. Infant was asleep in off limit bedroom on a couch with the door closed. Licensee states infant won't nap with others and will wake up others so she naps infant in that room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2021
Plan of Correction
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Licensee will submit a written plan of correction stating she understands safe sleep practices and that she understands she can not force an infant to sleep, infants are to sleep in crib or playpen.
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above. Licensee was alone with 4 infants and 3 pre school aged children while her assistant was on lunch which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2021
Plan of Correction
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Licensee will submit a written plan of correction stating what she will do to prevent this from reoccurring.
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: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 11/19/2021 04:21 PM - It Cannot Be Edited


Created By: Elizabeth Berumen On 11/16/2021 at 03:58 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: GARCIA CONTRERAS, LOURDES
FACILITY NUMBER: 434415579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review interview, the licensee did not comply with the section cited above; Licensee did not check on children napping in bedrooms with closed doors this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2021
Plan of Correction
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If an infant sleeping in a seprate room from where the provider is stationed, the door to the room from where the provider is stationed must be open. Licensee is to read section 102425
Infant Safe Sleep and submit a written statement stating she understands the regulation.
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. Infants are misisng the Individual Sleeping Plan (LIC 9227) in their file this is a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2021
Plan of Correction
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Licensee agrees to submit a copy of LIC 9227 for infants in care and keep original in infants file. Copy of LIC 9227 to be emailed or mailed to LPA elizabeth.berumen@dss.ca.gov
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: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 11/19/2021 04:21 PM - It Cannot Be Edited


Created By: Elizabeth Berumen On 11/16/2021 at 03:58 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: GARCIA CONTRERAS, LOURDES
FACILITY NUMBER: 434415579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)(2)
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. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review The Licensee has not began to utilize the LIC9227 form. This poses a potential risk to the Health, Safety or Personal Rights to children in care.
POC Due Date: 11/23/2021
Plan of Correction
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The LPA provided the Licensee with the LIC9227 form. The Licensee will immediately begin to utilize the form and ensure it is present in all the infants files.
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: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
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