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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416244
Report Date: 12/15/2020
Date Signed: 03/16/2021 12:30:49 PM

Document Has Been Signed on 03/16/2021 12:30 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:GONZALEZ, YAXINFACILITY NUMBER:
434416244
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
12/15/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Yaxin Gonzalez TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Stephanie Collins conducted a scheduled Tele-Pre-Licensing inspection via video conference call with Licensee Yaxin Gonzalez . LPA informed Licensee that due to the COVID-19 situation and "Shelter in Place" Order, this LIC809 Facility Evaluation Report was generated at the Licensing Office and will be e-mailed back to applicant. Your reply to the email will serve as acknowledgement that the report was received.

Licensing Program Analyst (LPA) Stephanie Collins conducted an unannounced inspection of the home in response to Licensee’s request to increase the capacity of her Family Child Care Home (FCCH) from 8 to 14 children. A Fire Clearance to obtain a Large Family Child Care Home License was granted on 01/18/2021. The home has been licensed as a small FCCH since 12/19/219; thus, the Licensee has over one years of experience that is required to apply for an increase to a Large FCCH. Licensee has current Pediatric First Aid and CPR certification.

Days and hours of operation are Monday through Friday from 8:00 AM to 6:00 PM. Licensee resides in the home with her two children, fiancé (Gillermo Ceballos) and sister (Nayomi Gonzalezl). All adults residing in the home have cleared background clearances, and proof of TB clearances. Licensee is reminded 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. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.
LPA had conducted an Pre- Licensing l Inspection of the home on 12/19/2019, see Facility Evaluation Report dated 12/19/2019 for details of the inspection. LPA observed an installed fire alarm, smoke and carbon monoxide detectors, and fully charged Fire Extinguished .
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2020
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: GONZALEZ, YAXIN
FACILITY NUMBER: 434416244
VISIT DATE: 12/15/2020
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LPA reviewed with Licensee the maximum capacity for a Large Family Child Care Home License. The maximum number of children for whom care may be provided at any one time when there is an Assistant Provider in the home, including children under age 10 who reside at the licensee's home shall be either:
(1) 12 children, no more than four of whom may be infants; or
(2) more than 12 and up to 14 children if at least one child is enrolled in and attending kindergarten or elementary school and a second child is at least six years of age and there are no more than three infants being cared for during any time when more than 12 children are being cared for.

When Licensee has more than 12 and up to 14 children in the home, Licensee must notify the parent using the form LIC-9150 “Parent Notification Additional Children in Care. LPA reminded Licensee that when Licensee does not have a Helper present, Licensee can only care for up to 8 children at any one time in the home and must follow the capacity requirement of a Small Family Child Care Home.

Licensee is reminded of the requirements and records needed to be maintained for Assistant Providers, which include but is not limited to Criminal Background Check Clearance, Tuberculosis Clearance, and Proof of immunity against Measles and Pertussis.

LPA reminded Licensee that there shall be at least one person with current Pediatric CPR and First Aid Certification with the children in care. Licensee has current Pediatric CPR and First Aid Certification that expires on 01/19/20221

No regulatory violations were NOT observed during the inspection.
Exit Interview was conducted, where this report was reviewed and discussed with Licensee. COVID-19 Self- Assessment completed.

Licensee was informed that her application for capacity increase to her Licenses will be submitted to Licensing Management for Final Approval- Pending
the fire clearance. Once the final approval has been received the Licensee will then be issued a license to operate a Large Family Child Care Home at this address .
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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