434416314-5-16-2022-07-CC-AMOS-CEGMMS-20220516094424

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416314
Report Date: 05/13/2022
Date Signed: 05/16/2022 09:45:42 AM

Document Has Been Signed on 05/16/2022 09:45 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:	GONZALEZ, YAXIN		FACILITY NUMBER:	434416314
ADMINISTRATOR:	GONZALEZ, YAXIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 813-5071
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 8	DATE:	05/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Yaxin Gonzalez		TIME COMPLETED:	04:25 PM

NARRATIVE

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Licensing Program Analyst (LPA) Anna Morales conducted an unannounced Annual Required visit and was greeted by Licensee Yaxin Gonzalez and her assistant. Today's census is eight children: two are under two years and six are ages from 2-5. The Day Care hours of operation are Monday - Friday, 7:00am - 6:00pm. The Licensee and her spouse are the only adults residing at the facility. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Last disaster drill was completed on 12/10/21.

LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe. Off limit areas inside Licensee's home: Bedroom One, Two and three, bathroom #1 and #3, side of house and gas/electric/ water shut off is located. There is a fence surrounding the backyard. LPA observed: fully charge 2A10BC fire extinguisher and working smoke/carbon monoxide detectors. No bodies of water observed. There is a covered fire place in the living room/day care room The Licensee states that she does not have any weapons. All detergents, cleaning compounds, poisons, medications, and other similar items are out of reach and inaccessible to children.

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SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

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: 434416314
	VISIT DATE: 05/13/2022

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. Licensee stated that she does provide IMS services. Licensee stores the medication(s) in a location that is inaccessible to the children. 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. Licensee has an area where sick children can be isolated from the others until parent pickup.

Licensee's Mandated Reporter Training (AB1207) expires in 12/28/2022 and her assistant expires 3/7/24. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

A random selection of children’s files were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization Records (PM286).

Licensee's and staff files were reviewed for the following records: Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). Licensee does have a current First Aid/CPR on file and it expires on 3/23/23.

LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes 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

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

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: 434416314
	VISIT DATE: 05/13/2022

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LPA discussed and left a copy of Pin 20-24-CCP, RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT. Discussed that all INFANTS UP TO 12 MONTHS OF AGE MUST HAVE AN INDIVIDUAL INFANT SLEEPING PLAN (LIC9227) ON FILE, WHICH WILL DOCUMENT THE INFANTS SLEEPING HABITS, USUAL SLEEPING ENVIRONMENT, AND THE INFANT ROLLING ABILITIES. PROVIDERS MUST CONDUCT CHECKS EVERY 15 MINUTES ON SLEEPING INFANTS (UP TO TWO YEARS OLD). Child Care Licensing Safe Sleep web page at:https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

LPA discussed the requirements of AB 633 with the Licensee and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations and advised that 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.

Exit Interview was conducted with Licensee. Type B deficiency cited and a copy of this report was provided to the Licensee. Appeals Rights Given

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.

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/inspection-process

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2022 09:45 AM - It Cannot Be Edited

Created By: Anna Morales On 05/13/2022 at 03:47 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: GONZALEZ, YAXIN	FACILITY NUMBER: 434416314
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

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, LPA did not observed a LIC9227 in C3 file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Licensee stated that she will submit a completed LIC9227 for C3 to CCL by the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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:

Diana Stephenson

LICENSING EVALUATOR NAME:

Anna Morales

LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC809 (FAS) - (06/04)

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