<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416010
Report Date: 07/30/2021
Date Signed: 08/03/2021 08:57:40 AM

Document Has Been Signed on 08/03/2021 08:57 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:LUIS, LENIFACILITY NUMBER:
434416010
ADMINISTRATOR:LENI LUISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 933-6392
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/30/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Leni LuisTIME COMPLETED:
10:25 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Deanna Villagrana met with applicant Leni Luis to conduct an announced pre-licensing inspection to the home today. The adults that reside in the home are the Applicant and three adult brothers.

Days and hours of operation will be Monday - Friday from 7:30 AM to 5:30 PM. Applicant has completed her Preventative Health and Safety Child Care Training on 02/20/2021 and a copy of the certification is on file. Applicant's CPR and First Aid certifications are current and expire on 009/29/2022. Applicant rents the home and has LIC9149 on file. Applicant does not have liability insurance and will issue affidavit regarding liability insurance for FCCH.

LPA toured the indoor and outdoor areas during today's visit. LPA observed a barricaded fireplaces and no stairs a in the home. Off limit areas inside the home: master bedroom/bath, two bedrooms and one bathroom, laundry room and kitchen. LPA observed a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide fenced backyard, and no bodies of water. Outdoor activities will be conducted in an area in the back of the home that is fenced of to the remaining part of the backyard. Off limit areas outdoor: fenced off area around the play 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. There are no animals in the home.

A review of staff records on 07/28/2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded Applicant of the applicable civil penalties for those adults who have not received fingerprint
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2021
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 2
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: LUIS, LENI
FACILITY NUMBER: 434416010
VISIT DATE: 07/30/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
clearances, are not associated to the license and who come 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 violation within a 12 month period.

Forms of discipline used by Applicant: talking to children and redirection. Applicant understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented. LPA discussed Safe Sleep regulations and provided PIN 20-24-CCP. A Family Child Care Home packet with updated Licensing forms was provided to and reviewed with the Applicant.

LPA discussed the requirements of AB 633 with the Applicant and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Applicant understands the requirements. LPA also discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 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. Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. SB 792 Immunization Requirements was also discussed. Applicant's immunization records are in file.

LPA conducted an exit interview with the Applicant and advised her that a large Family Child Care Home license is approved pending managers approval.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2