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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416495
Report Date: 04/29/2022
Date Signed: 04/29/2022 12:36:36 PM

Document Has Been Signed on 04/29/2022 12:36 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:ADVINCULA, EILEENFACILITY NUMBER:
434416495
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/29/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Eileen AdvinculaTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Janette Cruz met with Applicant, Eileen Advincula, to conduct an announced prelicensing inspection at 353 Vista Roma Way, San Jose 95136. The adults that reside in the home are the Applicant, her co-renter, Garriemor Navarro and Applicant's father, Napoleon Advincula. The Applicant also has two minor children (17-year old daughter & 8-year old son) residing in the home.

Days and hours of operation will be Monday - Friday from 6:00 AM to 8:00 PM. Applicant has completed her Preventative Health and Safety Child Care Training and a copy of the certification is on file. Applicant's CPR and First Aid certifications are current and expire on 09/24/23. Applicant completed Mandated Reporter Training on 09/03/2021. A copy of current TB test, flu, MMR, and Tdap vaccinations are on file. Applicant rents the home and a copy of lease agreement verifying control of property is on file. Applicant does not have liability insurance and will issue affidavit regarding liability insurance for Family Child Care Home (FCCH).

LPA toured the indoor and outdoor areas during today's inspection. LPA observed a two story home with 4 bedrooms, three bathrooms, living room, office, kitchen with dining area, play room and attached garage. The home has no backyard. There is a fireplace unit in the home located at the office/room which is an off-limit area. On-limit areas of the day care: Playroom, Living Room, Kitchen/Dining Room and 1st floor bathroom. Off limit areas inside the home are: Master bedroom with bathroom and three rooms on the 2nd floor, office on 1st floor and attached garage.

The home is clean and orderly, with heating/air conditioning, ventilation for safety and comfort. There is sufficient toys, supplies, and equipment for the day care children. LPA observed a fully charged fire extinguisher (1A10BC) and a smoke detector that did not activate an alarm sound when tested. LPA advised Applicant of the minimum requirements for fire extinguisher and working smoke and carbon monoxide detectors. LPA observed no bodies of water. LPA observed that Applicant has a pet tortoise kept inside a covered aquarium.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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: ADVINCULA, EILEEN
FACILITY NUMBER: 434416495
VISIT DATE: 04/29/2022
NARRATIVE
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Forms of discipline used by Applicant: talking to children/redirection. LPA advised that cleaning compounds and medications should be adequately stored and kept inaccessible to children. Applicant was reminded that any poison inside the home must be kept locked. The Applicant states that she does not have any baby walkers in the home. The Applicant understands that baby walkers are not allowed in the day care. The Applicant understands that high chairs are to be used only for eating purposes. The Applicant states that no adults smoke and she understands that smoking is prohibited in the home.

Applicant understands 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. LPAs informed Applicant that fire/disaster drills must be conducted at least once every 6 months and documented.

Eileen Advincula, Applicant, was 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 Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPAs discussed "zero tolerance" related regulations with the Applicant and advised her 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 discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-carelicensing/public-information-and-resources/safesleep as an additional resource. LPA also informed Applicant 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: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ADVINCULA, EILEEN
FACILITY NUMBER: 434416495
VISIT DATE: 04/29/2022
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APPLICANT 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 Applicant.

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 Applicant, Eileen Advincula, Applicant was advised that the following items need to be completed prior to approval of a small Family Child Care Home License:

1) Proof of purchase of working smoke and carbon monoxide detector
2) Photo of safety gate to barricade access to stairs going to second floor of the home and safety gate to barricade access to steps leading down to office and main door.
3) Photo of 65-inch television in living room secured or mounted to the wall for safety.
4) Proof of purchase of fire extinguisher that meet State Fire Marshal minimum standards.
5) Criminal record clearance, tuberculosis test clearance and LIC 508Criminal
Record Statement and Out-of-State Disclosure for Applicant's father- Napoleon Advincula currently residing and visiting in Applicant's home indefinitely.
6) Review and approval by Management.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC809 (FAS) - (06/04)
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