434416493-7-28-2022-07-CC-MSMS-CGRP24-20220728105520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416493
Report Date: 07/28/2022
Date Signed: 07/28/2022 10:55:30 AM

Document Has Been Signed on 07/28/2022 10:55 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:	CACERES AGELVIZ, RAMON & RODRIGUEZ AGELVIS, MILLY		FACILITY NUMBER:	434416493
ADMINISTRATOR:	RAMON & MILLY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(669) 233-1595
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95131
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 6	CENSUS: 5	DATE:	07/28/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Ramon Caceres Agelviz & Milly Rodriguez Agelvis		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mel Matos met with Applicants, Ramon Caceres Agelviz & Milly Rodriguez Agelvis, to conduct an announced prelicensing inspection at 1785 Ridgetree Way, San Jose, CA 95131. LPA was granted access to the home by both Applicants. LPA notes that the residence is currently licensed as a large Family Child Care Home (Zhayda Caceres Agelviz - #434413368) and five day care children were present during today's inspection. Current Licensee, Zhayda Caceres Agelviz will be closing out her license and moving out of the home as of Friday July 29, 2022. The Applicants and two adult daughters (Patricia & Alexandra Caceres Rodriguez) are the adults residing in the home. Current Licensee, Zhayda Caceres Agelviz will be closing out her license and moving out of the home as of Friday July 29, 2022. There are no minor children residing in the home. Days and hours of operation will be Monday - Friday from 8:30 AM to 5:30 PM. Applicants have completed their Preventative Health and Safety Child Care Training on June 25, 2021 and copies of the certifications are on file. Applicants CPR and First Aid certifications are current and expire on July 3, 2023. Applicants completed the Mandated Reporter Training for Child Care Workers on July 21, 2022 and copies of the certifications are on file. A copy of current TB test, flu, Mmr, and Tdap vaccinations for both Applicants are on file. Applicants rent the home and a copy of the lease agreement verifying control of property and Owner/Landlord Notification (LIC 9151) & Owner/Landlord Consent (LIC 9149) forms are on file. Applicants do not have liability insurance at this time and will issue Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282) until they obtain liability insurance. An approved fire clearance from the San Jose Fire Department was received on August 30, 2021. LPA toured the indoor and outdoor areas of the home with the Applicants during today's inspection. There are not stairs or wall heater units inside the home. Off limit areas in the home: master bedroom, master bathroom, one bedroom, furnace closet, locked bathroom vanity cabinet door, barricaded fireplace (located in the living room), and attached garage. Off limit areas outside the home: front yard and right side area of the backyard. The home is clean, orderly, (including heating/air conditioning), and ventilation for safety & comfort. There is sufficient toys, supplies, and equipment for the day care children both indoors/outdoors. LPA observed a fully charged fire extinguisher (3A40BC) and working combo smoke and carbon monoxide detectors, fenced backyard, and no bodies of water. Applicants state that they do not have any weapons/ammunition in the home.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: CACERES AGELVIZ, RAMON & RODRIGUEZ AGELVIS, MILLY	FACILITY NUMBER: 434416493
	VISIT DATE: 07/28/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Applicants state that they don't have any pets in the home. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. Applicants states that there are no poisons in the home. LPA reminded Applicants that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes. Applicants states that they will not administer any medication to the children at this time. Applicants state that a child will be isolated in the living room area if necessary due to illness or communicable disease. Applicant has a First Aid kit with a touchless thermometer in the home.

Forms of discipline used by Applicants: talking to children. Applicants understand that children's personal rights should not be violated; including no corporal punishment. isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed Applicants that fire/disaster drills must be practiced at least once every 6 months and documented.

Ramon Caceres Agelviz & Milly Rodriguez Algelviz, Applicants, were reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 discussed the requirements of AB 633 with the Applicants. The Applicants understand the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicants and advised them of the assessment of an immediate $500 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.

LPA provided and reviewed the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

LPA provided and discussed the safe sleep regulations with Applicants 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 Applicants 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

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: CACERES AGELVIZ, RAMON & RODRIGUEZ AGELVIS, MILLY	FACILITY NUMBER: 434416493
	VISIT DATE: 07/28/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

APPLICANTS WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:
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: http://www.ada.gov/childqanda.htm

PIN 22-02-CCP - Best Practices Related to the Provision of Incidental Medical Services in Child Care Center and Family Care Homes was provided to Applicants.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the Applicants, Ramon Caceres Agelviz and Milly Rodriguez Agelvis, and LPA advised them that a large Family Child Care Home License will be approved effective Friday July 29, 2022.

A signed letter from the existing Licensee, Zhayda Caceres Agelviz, indicating that she will be closing out her large Family Child Care Home license as of Friday July 29, 2022 was provided to LPA prior to the conclusion of today's inspection.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3