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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416049
Report Date: 01/31/2024
Date Signed: 01/31/2024 03:33:33 PM

Document Has Been Signed on 01/31/2024 03:33 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:BUGARIN, SANDRAFACILITY NUMBER:
434416049
ADMINISTRATOR:SANDRA BUGARINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 685-7090
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 11DATE:
01/31/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Sandra BugarinTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee's assistant Adriana Campos for a required three year visit. LPA explained the nature of today’s inspection to her. Licensee arrived a short time later. Present were licensee, licensee's mother, adult daughter, two assistants Adriana Campos and Johanna Alvarado and 11 day care children including three infants. Days and hours of operation are Monday to Friday, 7:30am to 5:30pm. The adults that reside in the home are licensee, her husband, her mother, adult daughter and 12 year old son.

A review of staff records on 01/25/2024 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Sandra Bugarin 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 toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed two infants asleep with blankets. The door to the room where infants were sleeping was closed and required assistant to move door to observe infants asleep. LPA observed a barricaded fireplace and stairs in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged 2A10BC fire extinguisher, a working smoke and carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: upstairs two bedrooms and downstairs master bedroom/bath, one bedroom, kitchen and attached garage that licensee uses as her dining room. There are no bodies of water.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: BUGARIN, SANDRA
FACILITY NUMBER: 434416049
VISIT DATE: 01/31/2024
NARRATIVE
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Backyard is fenced. Off limits outdoor: right side of home that is fenced off to children including locked storage. License states she has one dog and is vaccinated. LPA observed licensee has a current CPR and First Aid certification expiring 08/22/2025 and assistant Adriana's expires 12/26/2025. Licensee completed Mandated Reporter training on 01/18/2021. Both assistants have a current Mandated Reporter certificate on file.

LPA observed a current roster of the children. LPA observed a fire and disaster drill log was last completed on 07/24/2023. LPA reviewed 11 children's files and observed all forms are completed. Child 1, 5, 6, and 10 immunization records need to be updated. Licensee states day care is not insured. LPA discussed SB792 Immunization Requirements and observed licensee has immunization records on file.



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. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed the safe sleep regulations with licensee Sandra Bugarin 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 Sandra Bugarin 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 Zero Tolerance related regulations with licensee Sandra Bugarin and was advised of the assessment of $500 immediate civil penalty and an ongoing $100 per day per violation continues until the violation(s) is corrected. Incidental Medical services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800)514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
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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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: BUGARIN, SANDRA
FACILITY NUMBER: 434416049
VISIT DATE: 01/31/2024
NARRATIVE
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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.

Exit interview conducted and report was reviewed with the licensee Sandra Bugarin. During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPA Deanna Villagrana informed licensee Sandra Bugarin that this report dated 01/31/2024 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Deanna Villagrana informed the licensee Sandra Bugarin to provide a copy of this licensing report dated 01/31/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
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Document Has Been Signed on 01/31/2024 03:33 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 01/31/2024 at 02:56 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: BUGARIN, SANDRA
FACILITY NUMBER: 434416049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

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. LPA observed two infants asleep with blankets which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Licensee will submit a statement stating her and her assistants have read Safe Sleep regulations and understand the above regulation to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 01/31/2024 03:33 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 01/31/2024 at 02:56 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: BUGARIN, SANDRA
FACILITY NUMBER: 434416049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

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 record review, the licensee did not comply with the section cited above. LPA observed a fire and disaster drill log was last completed on 07/24/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee will conduct a fire and disaster drill and submit an updated log to CCLD by POC date.
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

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. The door to the room where infants were sleeping was closed and required assistant to move door to observe infants asleep which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee will submit a statement stating her and her assistants have read Safe Sleep regulations and understand the above regulation to CCLD by POC date.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 01/31/2024 03:33 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 01/31/2024 at 02:56 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: BUGARIN, SANDRA
FACILITY NUMBER: 434416049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)(A)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. The provider shall be able to visually observe the infant without moving the door.

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. The door to the room where infants were sleeping was closed and required assistant to move door to observe infants asleep which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee will submit a statement stating her and her assistants have read Safe Sleep regulations and understand the above regulation to CCLD by POC date.
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 record review, the licensee did not comply with the section cited above. Licensee completed Mandated Reporter training on 01/18/2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee will completed Mandated Reporter training and submit a current certificate to CCLD by POC date.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 01/31/2024 03:33 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 01/31/2024 at 02:56 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: BUGARIN, SANDRA
FACILITY NUMBER: 434416049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Child 1, 5, 6, and 10 immunization records need to be updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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2
3
4
Licensee will submit updated immunization records for child 1, 5, 6, and 10 to CCLD by POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024


LIC809 (FAS) - (06/04)
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