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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416362
Report Date: 05/07/2024
Date Signed: 05/07/2024 04:46:02 PM

Document Has Been Signed on 05/07/2024 04:46 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:PEREZ, MAYELIFACILITY NUMBER:
434416362
ADMINISTRATOR/
DIRECTOR:		PEREZ, MAYELIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 482-9136
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 14DATE:
05/07/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Mayeli PerezTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On 5/7/24 Licensing Program Analyst (LPA) Sheena Chin conducted an unannounced annual inspection at the facility. LPA met with Licensee, Mayeli Perez, and explained the nature of today’s inspection. Present during today’s inspection were the licensee, 2 helpers and 14 children in the facility. Among the 14 children there was not a child at least 6 years old. Days and hours of operation are Monday to Friday, 6:00am to 5:00pm. The adults that reside in the home are the licensee and her husband. The licensee stated she rented the home.

Observation
LPA observed that required postings were posted. LPA, along with the licensee, toured the inside and outside of the home. The facility has a full charged fire extinguisher, 2A10BC. Carbon monoxide and smoke detectors are working properly. In the backyard LPA observed there was a detached building, which was not included in the facility sketch. The licensee stated that that was for storage. LPA observed through the windows and learned that it was a living space. The licensee then stated that she did not rent the detached living space in the backyard. LPA observed that the living space had a sliding door toward the backyard. The licensee stated that the landlord used the living space for office and that she did not know when the landlord would come. LPA contacted the landlord over the phone, who agreed to finish background check and TB test. LPA advised the licensee to include the detached living space in the facility sketch. The off-limit areas inside in the home are bedroom #1, bedroom #2, kitchen, garage, and the living space in the backyard.

All disinfectant, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible. LPA observed that there are toys for children inside and outside of the house. LPA conducted CARE Tools for this annual inspection, which include Physical Plant, Care and Supervision, Facility Administration, Records, Staffing Ratio and Capacity, Personnel Rights for compliance with all licensing statutes, regulations, and interim licensing Standards, and results were documented on the tool.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PEREZ, MAYELI
FACILITY NUMBER: 434416362
VISIT DATE: 05/07/2024
NARRATIVE
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Page 2.

Records review
The Licensee has current CPR and First Aid certifications expiring 1/29/25. The Licensee has the child abuse training certificate, expiring 2/3/26. LPA reviewed the fire and disaster drills log which is to be done at least once every six months. The last drills were conducted on 4/29/24. LPA reviewed helpers and children’s files. Immunization records are maintained and updated in form PM 286. LPA observed Notification of Parents’ Rights and consent for emergency medical treatment were in each child’s file. Mandated reporter training certificate was not observed for S2.

During today’s inspection, all adults present or residing in the home have criminal record clearances required by the Department. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Discussion


Supervision of children was discussed with Licensee, who 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. Licensee states that she does not transport children via vehicle but she understands that children cannot be left in parked vehicles unattended at any time.

LPA discussed the safe sleep regulations with licensee 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 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.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PEREZ, MAYELI
FACILITY NUMBER: 434416362
VISIT DATE: 05/07/2024
NARRATIVE
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Discussion
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/. The Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Deficiency
Regulatory violations were observed during today’s inspection and citation were issued.

Further questions
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.

Exit
During the exit interview, the Licensee, Mayeli Perez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Exit interview was conducted, where this report, the citation, plan of correction, and appeal rights were reviewed and discussed with Licensee, Mayeli Perez. Notice of site visit was given and must remain posted for 30 days.
LPA advised the director to print out this licensing report and deficiency report for parents to review and have parents sign LIC 9224 form. LPA advised the director that a copy of this report shall be provided to parent/guardian of any newly enrolled children for the next 12 months. LPA advised the director to post this report and the Notice of Site Visit for 30 days. Failure to maintain postings as required will result in an immediate $100 civil penalty.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/07/2024 04:46 PM - It Cannot Be Edited


Created By: Sheena Chin On 05/07/2024 at 04:04 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: PEREZ, MAYELI
FACILITY NUMBER: 434416362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(2)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, 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 and the assistant provider's children under age 10, shall be either: (2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. During today's inspection there're 14 children and among the 14 children there was not a child at least 6 years old, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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The licensee stated that she would tell the parents who enrolled their child last week that she's unable to take the child starting tomorrow and have the pre-K child's parents send their child to school starting tomorrow. Licensee stated that she would report tomorrow's attendance to LPA and send LPA a statement, acknowldeging the capacity requirement for larg family child care homes
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Sheena Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/07/2024 04:46 PM - It Cannot Be Edited


Created By: Sheena Chin On 05/07/2024 at 04:04 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: PEREZ, MAYELI
FACILITY NUMBER: 434416362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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. Mandated reporter training certificate was not observed for S2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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The licensee will send LPA the valid mandated reporter training certifcate for S2.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Sheena Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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