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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416164
Report Date: 08/19/2021
Date Signed: 08/24/2021 08:52:55 AM

Document Has Been Signed on 08/24/2021 08:52 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:ROSENBERG, ELANAFACILITY NUMBER:
434416164
ADMINISTRATOR:ELANA ROSENBERGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 801-0840
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 11DATE:
08/19/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Elana Rosenberg TIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Larios met with Alma Duff, Licensee, for an unannounced Required – 1 year annual inspection. LPA were granted access to the home by the Licensee. LPA also observed 11 children. The Licensee was operating within her capacity and ratio requirements during today's inspection. LPA observed the required postings, including the facility license, near the front entrance to the home. The home has a working telephone (310)801-0840. Days and hours of operation are Monday - Friday from 2:00PM to 6:00PM. The Licensee and spouse are the only adults residing in the home. Licensee has three daughters under the age of 18 years. The Licensee CPR and First Aid was not current and expired on 5/31/2021 and assistant did not have one in file.

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The Licensee, Licensee's assistant, have the required vaccinations (MMR, Tdap, & flu). The Licensee does not have current Mandated Reporter Training for Child Care Workers on file or assistant. LPA reviewed children's files and observed current and updated Identification and Emergency Information (LIC 700) and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. The Licensee states that a child will be isolated in the front entry way of the day care room if needed to because of illness or communicable disease.

Safe sleep updated: LPA discussed the new “Safe Sleep” regulations with the Licensee and provided a copy of the regulations, including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee.

REPORT CONTINUED ON FOLLOWING PAGE #2 - REPORT DATED 08/19/2021
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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: ROSENBERG, ELANA
FACILITY NUMBER: 434416164
VISIT DATE: 08/19/2021
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 08/19/2021)
LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.

LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed sufficient materials, toys, and play equipment for the day care children. LPA observed in the backyard where child play two propane tanks, pressure cleaner, two ladders and other debris accessible to children. There are stairs inside the garage that is off limits. There is a fireplace inside the home that is screened. Off limit areas children bedroom, master bedroom, master bathroom, laundry room, and back yard storage.

LPA observed a fully charged 2A10BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, poisons, medications, and other similar items are out of reach and inaccessible to children.

A review of staff records on August 19,2021 indicates that not all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded the Licensee of the applicable civil penalties for those adults who have not received fingerprint 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.

REPORT CONTINUED ON FOLLOWING PAGE #3 - REPORT DATED 08/19/2021
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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: ROSENBERG, ELANA
FACILITY NUMBER: 434416164
VISIT DATE: 08/19/2021
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 08/19/2021)
Supervision of children was discussed with the 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. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time without a fully qualified adult present. The 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.

LPA discussed the requirements of AB 633 with the Licensee and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and the Licensee understands the requirements. LPA also discussed "zero tolerance" related regulations with the Licensee and advised her of the assessment of an immediate $500 per day 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.

Website for provider resources:
http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA conducted an exit interview with the Licensee and deficiencies were issued during today's inspection.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/24/2021 08:52 AM - It Cannot Be Edited


Created By: Elizabeth Larios On 08/19/2021 at 05:19 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: ROSENBERG, ELANA
FACILITY NUMBER: 434416164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2021
Section Cited
CCR
102370(d)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 102370(j)
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By 5 PM on 08/20/2021, Licensee will provide transfer requests for her assistant along with valid government issued photo ID to CCL office.
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This requirement was not met as evidenced by: Based on observation that the Licensee failed to transfer one assistant to the facility, which poses a potential risk to the health and safety of the children in care.
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Type B
08/19/2021
Section Cited
HSC1596.8662(4)(b)(1)

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1596.8662 (4)(b)(1)On or before 03/30/18, a person who on 01/01/18 is a licensed child day care provider shall complete the mandated reporter training......every two years following the date on which she completed the initial mandated reporter training. This requirement is not met as evidenced by:
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Licensee will submit a mandated reporter training certificate for her self and assistant by POC date 08/26/2021.
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Based on observation and record reviews, Licensee has no current mandated reporter training certificate on file or assistant which poses a potential threat on health and safety of children.
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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:Anthony Studebaker
LICENSING EVALUATOR NAME:Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021


LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 08/24/2021 08:52 AM - It Cannot Be Edited


Created By: Elizabeth Larios On 08/19/2021 at 05:28 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: ROSENBERG, ELANA
FACILITY NUMBER: 434416164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2021
Section Cited
CCR
102416(c)

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102416 (c) Personnel Requirements
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:
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Licensee and assistant shall submit a current preventive health practices including pediatric cardiopulmonary and pediatric first aid certificate by POC date 08/26/2021.
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Based on record reviews, Licensee's and assisant pediatric CPR and first aid certificate was expired or not in file which poses a potential threat on health and safety of children on care.
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Type B
08/19/2021
Section Cited
CCR102417(g)(4)

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Operation of a Family Child Care Home. 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 was not met as evidenced by: LPA observed in the
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Licensee removed some of the the items such as the two porpane tanks but shall remove the rest of the debris that pose a risk to the health and safety to children in care and stored them inaccessible to the children by submitting proof by POC date 08/26/2021 to CCL office.
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backyard where child play two propane tanks, pressure cleaner, two ladders and other debris accessible to children.This poses a potential risk to the health and safety to the children in care.
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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:Anthony Studebaker
LICENSING EVALUATOR NAME:Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021


LIC809 (FAS) - (06/04)
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