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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416445
Report Date: 11/15/2024
Date Signed: 11/15/2024 03:21:46 PM

Document Has Been Signed on 11/15/2024 03:21 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: 12DATE:
11/15/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Staff #1 TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jennifer "Jen" Beehler met with Staff #1 (S1) for a plan of correction follow up visit from the Annual visit that was conducted on 11/06/2024. Upon arrival, LPA was greeted by Staff #1 (S1) and provided access to the property. LPA stated the reason for the visit was to follow up on the plan of correction and to discuss day care changes.

LPA observed 12 children in care and three staff people present, two of the children were under 24 months. This is compliant with ratio regulations. S1 stated Co-licensee, Tabitha, was not available today as she was under the weather. LPA asked if she could speak with co-licensee. S1 stated she was not on the property, that she had went to her family's home to not infect children in care. LPA stated that licensee is only permitted to be away from the property 20% of each day. LPA stated if licensee is not well enough to care for children, the facility should close down. LPA asked where Tamara was and S1 stated she no longer lives in the home.

LPA reviewed all children's files and observed the completed Infant Sleep plan for infants in care and the LIC9224 with the last report dated and signed by child's representative. S1 stated the PM286 was confusing and she needed assistance with the paperwork. LPA asked if S1 and Co-licensee would benefit from a resource and referral agency (R&R). S1 stated they would appreciate the help. LPA will make a referral and someone will reach out to assist in paperwork and any other question they may have.

Infant sleep regulations were discussed and LPA reminded licensee that infants 0-24 months need a sleep check every 15 minutes while napping. The sleep check should denote what position they are in, if there is anything to note such as labored breathing, the time and initials of staff person who completed the check. Records should be kept in child's file for the extent that the child is in care. Infant sleep plan is for 0-12 months and relates to an infant's ability to flip themselves or if the provider needs to do it for them, until they are capable. S1 stated she understood the difference and will comply.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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: AVILLA, TAMARA & RIVERA, TABITHA
FACILITY NUMBER: 434416445
VISIT DATE: 11/15/2024
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S1 will discuss with Tabitha Rivera, Co-licensee about updating the LIC279. S1 said they would work on it together.

Due to today's inspection, no deficiencies were cited. Exit interview conducted with S1, report was reviewed and provided. LPA provided appeal rights from last visit. A 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: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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