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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416720
Report Date: 03/20/2025
Date Signed: 03/20/2025 11:30:22 AM

Document Has Been Signed on 03/20/2025 11:30 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CRUZ, KARINAFACILITY NUMBER:
434416720
ADMINISTRATOR/
DIRECTOR:		KARINA, CRUZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 717-3618
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
03/20/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Karina CruzTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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At 8:45AM, Licensing Program Analyst (LPA) Angela Luz met with Licensee Karina Cruz to conduct an unannounced annual RANDOM inspection. Present for this inspection was 2 infants, 7 preschool aged children, and 2 fingerprint cleared staff. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from Monday – Friday 7:30AM-6PM. English and Spanish are spoken to the children in care. Licensee is bilingual in English and Spanish.

Facility:
The OFF LIMIT AREAS are the garage, primary bedroom, primary bathroom and side yard. The ON LIMIT AREAS are the home day care area, patio deck, patio, daycare bathroom, and bedrooms 2 and 3. Bedrooms 2 and 3 are not currently being used for daycare purposes. Off limit areas are inaccessible by closed and/or locked doors and visual supervision. The home is neat and clean with heating and ventilation for safety and comfort. The ISOLATION AREA is front home day care area. The outdoor play area is free from defects or dangerous conditions and is fully fenced. LPA observed a sturdy play structure with a slide, swing set, and climbing wall with turf underneath. There have been no changes from the areas previously identified as OFF LIMITS or alterations to existing building or grounds. There are no bodies of water. All hazardous materials and toxins are kept out of the reach of children in high cabinets. Licensee states that there are no firearms in the home. The home has a fully charged 3A40BC fire extinguisher that was last serviced on 1/11/25, working smoke detector, working carbon monoxide detector, and working telephone. LPA reminded that fire extinguishers should be serviced once a year.

Care and Supervision: There are ample age-appropriate toys that appear to be safe and in good condition. Licensee uses talking with the child and redirection as forms of discipline. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, interference with eating, intimidation, or other actions of a punitive nature. Children are treated with dignity, receive safe, healthful, and comfortable accommodations. Licensee understands how to report unusual incidents/injuries. ***Page 1 of 3***
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Angela Luz
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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: CRUZ, KARINA
FACILITY NUMBER: 434416720
VISIT DATE: 03/20/2025
NARRATIVE
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LPA observed 2 of 2 play yards meet the safety standards. The play yards do not hinder entrance or exit to and from the space where infants are sleeping. The mattresses in the play yards are firm and covered with a fitted sheet that is appropriate, fits tightly, and overlaps the underside of the mattresses. Each infant’s bedding is used for them only and cleaned daily or before use by another infant. There are no loose articles and objects, bumper guards or objects hanging above or attached to the side of the cribs or play yards. LPA reviewed and gave copies of PIN 20-24-CCP and Title 22 Section 102425 Infant Safe Sleep with Licensee. Licensee understands Infant Safe Sleep requirements.

Records: The Licensee CPR and First Aid certificate is current and expires 1/18/27. Licensee Mandated Reporter Training for Child Care Providers is current and expires 8/15/25. Licensee was reminded of Mandated Reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the licensee’s immunization is on file. The Licensee conducts and documents fire and disaster drills every six months, last drill was on 10/6/24. A current copy of the facility roster was viewed, and a copy was obtained. Affidavit Regarding Liability Insurance (LIC 282) were found in children’s files. Entrance checklist for Family Child Care Home was provided and licensee was reminded of documents to be posted in a prominent, publicly accessible area of the facility.

LPA reviewed five (5) children files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization records. Each infant under 12 months of age has an Individual Infant Sleeping Plan maintained in the file signed and dated by the infant’s authorized representative. Documentation of infant sleep checks every 15 minutes that notate any signs of distress are maintained in their file. All children’s files reviewed today were complete. LPA, Luz reviewed three (3) staff (S1-S3) files for the following records: Employee rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunization records, and required training. Staff 3 was missing proof of required immunizations. Staff 1 and 2 files were complete.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.
***Page 2 of 3***
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Angela Luz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
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: CRUZ, KARINA
FACILITY NUMBER: 434416720
VISIT DATE: 03/20/2025
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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 discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. 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.

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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE, Karina Cruz, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Megan's Law was checked on 3/12/25.

During today's inspection, 1 Type B deficiency is issued on attached page 809-D
  • Staff 3 missing proof of required immunizations.
Appeal rights were provided.
A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with the Licensee, Karina Cruz.
***Page 3 of 3***
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Angela Luz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2025 11:30 AM - It Cannot Be Edited


Created By: Angela Luz On 03/20/2025 at 10:57 AM
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: CRUZ, KARINA
FACILITY NUMBER: 434416720

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review of staff files, the licensee did not comply with the section cited above in 1 out of 3 immunization records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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By plan of correction due date, Licensee will submit proof of MMR and TDap immunizations for Staff 3.
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:Belinda Devall
LICENSING EVALUATOR NAME:Angela Luz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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