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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416752
Report Date: 03/29/2023
Date Signed: 03/29/2023 03:36:57 PM


Document Has Been Signed on 03/29/2023 03:36 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:MALDONADO, LAURAFACILITY NUMBER:
434416752
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lina Maldonado and Mauricio Cristancho
TIME COMPLETED:
04:00 PM
NARRATIVE
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On 03/29/23 at 10:02 AM, Licensing Program Analyst (LPA) Teodoro Trujillo was greeted by assistant Lina and was allowed onto the premises for an annual inspection and change of capacity visit, LPA explained the reason for the visit to her. Licensee was inside the home with her newborn infant child. Present during today's visit were licensee, spouse Mauricio who assists with day care, assistant Lina and licensee mother Esperanza who is visiting with 6 children: three preschool and three infants. Adults living in the home are licensee, spouse Mauricio and adult sister Lina. Days and hours of operation are Monday through Friday 7:30 AM to 5:30 PM.
A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 3/20/23 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, 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 inspected inside and outside of the home. LPA observed a barricaded fireplace inside the home, no wall heater, unlocked barricaded stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated they have no pets. LPA observed a fully charged 2A10BC fire extinguisher that has not be serviced since 2021. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Off limit areas: second floor and left side of back yard area, kitchen and attached garage. Outside on backyard LPA observed left side fence needs to be repaired, 20 foot section has loose boards and right fence section near garage is missing fence that fell during winter storm 2 weeks ago. Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 8 children according to their license. Licensee stated they do not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.

Continues on report dated 03/29/2023 pg. 1/2

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MALDONADO, LAURA
FACILITY NUMBER: 434416752
VISIT DATE: 03/29/2023
NARRATIVE
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Continuation of report dated 03/29/23 pg. 2/2
LPA observed a fire and disaster drill log that was last conducted on 06/22/2022. LPA reviewed 5 children’s files. The 15 minute check sleep log for infants under 24 months was discussed, licensee provided completed sleep logs, LPA reviewed and observed they were missing the 15 minute sleep check. LPA observed that the Licensee has Mandated Reporter training, training was completed on 12/01/2021, assistant Mauricio completed 1/07/23 and assistant Lina completed on 1/26/22. Licensee has Pediatric CPR/1st Aid expiring 12/5/2024, assistant Mauricio expiring on 9/30/2024 and assistant Lina expiring 8/21/2023. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for Licensee and assistant Lina, assistant Mauricio is missing MMR(measels vacinne).

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

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-and-resources/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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Type B deficiencies were cited during today's visit. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made and before Licensing Program Manager (LPM) approval for a large day care license for 14 children. Exit interview conducted and report was reviewed in Spanish with the licensee, Laura Maldonado. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/29/2023 03:36 PM - It Cannot Be Edited

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: MALDONADO, LAURA
FACILITY NUMBER: 434416752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview), the licensee did not comply with the section cited above in cushioning material is missing on children's swing set up on concrete slab, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2023
Plan of Correction
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Licensee states she will install cushioning material for swing set and submit pictures of installed product to the San Jose Regional Office by close of business 04/13/2023.
Type B
Section Cited
CCR
102417(g)(3)
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: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview), the licensee did not comply with the section cited above in stair gate door was shut, not secured with gate lock, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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assistant secured door immediately during site visit, licensee will have a meeting with all day-care assistants and will submit a written plan on preventing deficiency to the San Jose Regional Office by 3/31/23.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 03/29/2023 03:36 PM - It Cannot Be Edited

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: MALDONADO, LAURA
FACILITY NUMBER: 434416752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in last disaster drill was conducted on 06/22/2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Licensee will submit a copy of documented disaster drill log to the San Jose Regional Office by close of business 03/31/2023.
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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above in assistant Mauricio is missing MMR (measles) vaccination, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2023
Plan of Correction
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Licensee will submit a copy of Vaccine for assistant Mauricio by close of business 04/13/2023.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/29/2023 03:36 PM - It Cannot Be Edited

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: MALDONADO, LAURA
FACILITY NUMBER: 434416752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Date of birth missing for all children in care, licensee infant child missing from roster, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2023
Plan of Correction
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Licensee updated roster during site visit, deficency cleared.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in The 15 minute check is missing from the printout from the Phone Application licensee utilizes to document the Infant sleep for children in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2023
Plan of Correction
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Licensee will start using a manual log and will subit a copy of 15 min sleep logs for all infants in care to the San Jose Regional Office by close of business 04/13/2023.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7