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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416445
Report Date: 11/06/2024
Date Signed: 11/06/2024 05:19:36 PM

Document Has Been Signed on 11/06/2024 05:19 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:AVILLA, TAMARA & RIVERA, TABITHAFACILITY NUMBER:
434416445
ADMINISTRATOR/
DIRECTOR:		TAMARA & TABITHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 718-0230
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 14DATE:
11/06/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Tabitha Reyes-RiveraTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Staff #1 (S1), for an unannounced Required- 1 Year Inspection. LPA was granted access to the home by the S1 and toured both indoors and outdoors during the inspection. Licensee was not present upon arrival and arrived back to the property at 2:45 PM. Upon arrival, there were 14 children (3 infants and 11 preschool aged children) and 3 staff members present, which is compliant with the home license capacity and ratio requirements. LPA observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Friday, 08:15AM-04:45PM, early drop off on Tuesdays and Fridays at 7:45 AM. There are no current waivers or exceptions.

Licensee states that adults, over the age of 18, residing in the home are: herself and co-licensee Tamara Avila. All adults present and residing in the home have Criminal Background Check Clearance and signed Criminal Record Statements (LIC508). 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.

LPA reviewed facility roster (LIC9040) and fire/disaster drill log during today's inspection. The last fire/disaster drill was conducted on 05/28/2024, which is compliant with the six month requirement for homes. LPA observed a fully charged 2A10BC fire extinguisher which was manufactured in 2024, there also was a functioning smoke detector and carbon monoxide detector. LPA reminded licensee that fire extinguishers need to be serviced every year or replaced per Fire Marshall regulation. Licensee states that she does not currently have any children in care who require Incidental Medical Services.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AVILLA, TAMARA & RIVERA, TABITHA
FACILITY NUMBER: 434416445
VISIT DATE: 11/06/2024
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

The Licensee states that there are no weapons or firearms in the home.

Indoor areas of the home were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. Off-limits areas of the home (indoors): 1 bedroom and ensuite bath, kitchen, laundry room. Fireplace in the front living room was barricaded so it is inaccessible from infants in care. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. Drinking water is readily available for children in the facility via filter water and reusable cups from home and are labeled. Parents take them home each night to clean and bring them back each day. Two bathrooms for children in care, they are clean, sanitary, and operable. The Licensee has a cell phone for facility number. Licensee talks to parents every day at pick up and drop off. They use a Brightwheel application to share information with parents daily. Stairs are blocked off from children unless walking from day care room to day care room supervised with staff.

The backyard area of the home was inspected. LPA observed sufficient play equipment and supplies for the children that are in good condition and age-appropriate. Off-limit areas outside of home include: front yard. No outdoor bodies of water were observed during today's inspection.

Infant Safe Sleep regulations (PIN 20-24-CCP) were discussed with the Licensee, including the Individual Infant Sleeping Plan (LIC9227). LPA reminded Licensee that infants up to 12 months of age should be placed on their back to sleep, that cribs should be free of all loose articles and hanging objects, and that infants should not be swaddled.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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: AVILLA, TAMARA & RIVERA, TABITHA
FACILITY NUMBER: 434416445
VISIT DATE: 11/06/2024
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 Infants should be supervised while sleeping and documentation of sleep checks every 15 minutes should remain in the infant’s file. Documentation should include the time of the check, the infant’s physical condition, and initials of the staff member checking on the infant. Records were kept on a digital app and not placed in the file. LPA discussed ways to make these records regularly accessible to licensing and parents.

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.

4 children’s files were reviewed during todays inspection and some required documents were present, including Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC282), Immunization Records. One file was missing immunization records. 3 of 4 children's immunization were not transferred to PM286. 3 out of 3 infants in care did not have an infant sleep plan in the file.

2 staff files (licensee and assistant) were reviewed. Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza declination. There is at least one staff member present with current CPR/First-Aid that expires 08/28/2025. The Licensee has current Mandated Reporter Training that expires on 08/28/2025 and LPA reminded that training must be renewed by all staff every 2 years. LPA reminded licensee when choosing the mandated reporter training to choose the "Child Care Providers" class that satisfies the requirement for AB1207.

Supervision of children was discussed with the Licensee and she understands that she must be home during day care hours and ensure that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should 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 observed an infant in a restraining device during today's inspection. LPA discussed the regulation and licensee removed the device immediately and stated she would not use it or other devices like that.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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: AVILLA, TAMARA & RIVERA, TABITHA
FACILITY NUMBER: 434416445
VISIT DATE: 11/06/2024
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Due to today's inspection, one Type A and one Type B deficiencies were issued and can be reviewed in the attached LIC809-D. There are also three technical violations attached to this report.

Exit interview conducted with Licensee, Tabitha Reyes-Rivera and report was reviewed and presented along with appeal rights. NOTICE OF SITE VISIT WAS PROVIDED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 05:19 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 11/06/2024 at 04:25 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: AVILLA, TAMARA & RIVERA, TABITHA
FACILITY NUMBER: 434416445

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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 in 3 out of 3 children's files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Licensee to complete infant sleep plan for all infants under 12 months old and provide a copy to LPA and keep in the file. Licensee will include an infant sleep plan for all children admitted into care under 12 months old.
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:Joel Segura
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/06/2024 05:19 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 11/06/2024 at 04:25 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: AVILLA, TAMARA & RIVERA, TABITHA
FACILITY NUMBER: 434416445

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(10)
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: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in as a restraing device was used for one of the infants in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2024
Plan of Correction
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Licensee removed restraining device during the inspection and stated she will no longer use it for children in care.
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:Joel Segura
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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