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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416430
Report Date: 05/12/2022
Date Signed: 05/12/2022 01:22:33 PM

Document Has Been Signed on 05/12/2022 01:22 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:FERNANDEZ, ARMINDAFACILITY NUMBER:
434416430
ADMINISTRATOR:FERNANDEZ, ARMINDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 767-0431
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 4DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Arminda FernandezTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Arminda Fernandez for a required one year visit. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's adult son and four day care children. Days and hours of operation are Monday to Friday, 6:00am to 6:00pm. The adults that reside in the home are licensee and adult son. LPA observed a storage attached to the garage was converted into a studio for habitat. Licensee did not inform the Department. Licensee stated her sister Monica Fernandez lives in the studio with her minor child. Licensee has not obtained a City Permit for conversion.

A review of staff records on 05/06/2022 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 observed Licensee's sister Monica Fernandez does not have Criminal Record Clearance. Licensee Arminda Fernandez 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 did not observe stairs or a fireplace in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed cleaning products, shampoos, conditioners and body washes accessible to children in the bathroom children use. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed a working smoke detector and a working carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: three bedrooms and laundry room. There are no bodies of water. Backyard is
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: FERNANDEZ, ARMINDA
FACILITY NUMBER: 434416430
VISIT DATE: 05/12/2022
NARRATIVE
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fenced. Off limits outdoor: right side of home that is fenced off to children including two locked storages. Licensee states there are no animals in the home. LPA observed licensee has a current CPR and First Aid certification expiring 10/13/2023. Licensee has not completed Mandated Reporter training. Training can be found at www.mandatedreporterca.com

LPA did not observe a current roster of the children. Fire and disaster drill log was last completed on 06/02/2021. LPA reviewed four children's files. Child 2 and 3 immunization records need to be updated. Child 4 does not have immunization records. Licensee states day care is not insured. Child 4 does not have LIC282. Licensee's adult son does not have LIC508 on file. 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 Arminda Fernandez 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 Arminda Fernandez 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 Arminda Fernandez 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: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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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: FERNANDEZ, ARMINDA
FACILITY NUMBER: 434416430
VISIT DATE: 05/12/2022
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 Arminda Fernandez.

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 Arminda Fernandez that this report dated 05/12/2022 document(s) 3 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 Arminda Fernandez to provide a copy of this licensing report dated 05/12/2022 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: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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Document Has Been Signed on 05/12/2022 01:22 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 05/12/2022 at 12:39 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: FERNANDEZ, ARMINDA
FACILITY NUMBER: 434416430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) 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 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 cleaning products, shampoos, conditioners and body washes accessible to children in the bathroom children use which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Licensee removed items during visit. Deficiency cleared today.
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) 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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA observed Licensee's sister Monica Fernandez does not have Criminal Record Clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Licensee's sister will go get fingerprinted and understands she may not be in the home until she receives Criminal Record Clearance.
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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


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Document Has Been Signed on 05/12/2022 01:22 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 05/12/2022 at 12:39 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: FERNANDEZ, ARMINDA
FACILITY NUMBER: 434416430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.3(a)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed a storage attached to the garage was converted into a studio for habitat. Licensee did not inform the Department. Licensee stated her sister Monica Fernandez lives in the studio with her minor child. Licensee has not obtained a City Permit for conversion which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Licensee will submit a City Permit for converted studio along with an updated sketch of the facility to CCLD by POC date.
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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


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Document Has Been Signed on 05/12/2022 01:22 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 05/12/2022 at 12:39 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: FERNANDEZ, ARMINDA
FACILITY NUMBER: 434416430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

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. Fire and disaster drill log was last completed on 06/02/2021. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2022
Plan of Correction
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Licensee will conduct a fire and disaster drill and submit 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 interview, the licensee did not comply with the section cited above. Licensee has not completed Mandated Reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2022
Plan of Correction
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Licensee will submit a current Mandated Reporter training 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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


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Created By: Deanna Villagrana On 05/12/2022 at 12:39 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: FERNANDEZ, ARMINDA
FACILITY NUMBER: 434416430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(11)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (11) A signed statement regarding their criminal record history as required by Section 102370(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Licensee's adult son does not have LIC508 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2022
Plan of Correction
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Licensee's son will complete LIC508 and submit to CCLD by POC date.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above. Child 4 does not have immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2022
Plan of Correction
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2
3
4
Licensee will submit immunization records for child 4 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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


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Document Has Been Signed on 05/12/2022 01:22 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 05/12/2022 at 12:39 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: FERNANDEZ, ARMINDA
FACILITY NUMBER: 434416430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
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.

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 2 and 3 immunization records need to be updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2022
Plan of Correction
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2
3
4
Licensee will submit updated immunizations for child 2 and 3 to CCLD by POC date.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

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 observe a current roster of the children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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2
3
4
Licensee completed roster during visit. Deficiency cleared today.
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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


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Document Has Been Signed on 05/12/2022 01:22 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 05/12/2022 at 12:39 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: FERNANDEZ, ARMINDA
FACILITY NUMBER: 434416430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

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 4 does not have LIC282 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2022
Plan of Correction
1
2
3
4
Licensee will submit LIC282 for child 4 to CCLD by 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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


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