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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416762
Report Date: 03/30/2023
Date Signed: 03/30/2023 06:54:03 PM

Document Has Been Signed on 03/30/2023 06:54 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:REYNOSO, ANA KARINAFACILITY NUMBER:
434416762
ADMINISTRATOR:REYNOSO, ANA KARINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 843-8923
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Ana Karina Reynoso OrtegaTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Samantha Yip and Ashley Lopez conducted an unannounced Required- 1 Year inspection. LPAs met with Licensee's Assistant and explained the reason for the inspection. Licensee Ana Karina Reynoso Ortega arrived shortly after. LPAs explained the reason for the inspection. Upon arrival, A-1 was alone with 11 children. There were no infant age children present during today's inspection. LPA discussed with Licensee the ratio and capacity. All adults present have cleared fingerprints.

There is board to post required posting, such as license and notification of parent's rights. The hours of operation are Monday through Sunday 3AM to 8PM.

LPA toured the inside and outside of the home. The off-limit areas are bedroom 2, bedroom 3, and bedroom 4. LPA observed that the sliding door in bedroom 4 that leads to the backyard was open. There were no children outside at the time. LPA discussed with Licensee that the door needs remain close at all time. There is fireplace in the home, which is barricaded. Disinfectant, cleaning supplies, and other items that could pose a risk to children were inaccessible to children. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 03/06/2023.

The backyard is used and is fenced. The off-limit area outside is the right side of the yard, the ADU, and the uncovered garage. There are two sheds in the backyard, which had a lock. The locks were not locked. LPA observed that there was cleaning supplies, insect spray, and a saw. Licensee locked the shed during today's inspection. There were no bodies of water observed during today's inspection. LPA reminded Licensee to ensure that anything that collects water is dumped out.

--------------------continues on 809 dated 03/30/2023 page 2---------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: REYNOSO, ANA KARINA
FACILITY NUMBER: 434416762
VISIT DATE: 03/30/2023
NARRATIVE
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-----------------continuation of 809 dated 03/30/2023 page 1--------------------

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. LPA discussed with Licensee that the door needs to remain open if there are any infants sleeping in the bedroom and there cannot be anything in the crib, such as blankets.

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

Licensee and her daughter, who helps with the daycare, transports children and have a valid driver's license. Licensee understands that children cannot be left alone and unattended in parked vehicles.

A copy of the facility roster was obtained during today's inspection. Five (5) children's files were reviewed during today's inspection. The records reviewed include but not limited to parent's rights and consent for emergency medical treatment. LPA discussed about ensuring that she is using the correct form.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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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: REYNOSO, ANA KARINA
FACILITY NUMBER: 434416762
VISIT DATE: 03/30/2023
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----------------continuation of 809 dated 03/30/2023 page 2----------------------

Two assistant's files were reviewed. The records reviewed include but not limited to Mandated Reporter training and employee rights. Licensee and her two assistants completed the Mandated Reporter training on 03/2021. Licensee and her assistant completed the Mandated Reporter training on 03/2023 through the Child Care Providers United, but has not received her certificate yet. Licensee will send proof of registration and certificate to Licensing. Licensee's CPR/1st Aid expires on 07/09/2024 and A-1's CPR/1st Aid expires on 10/18/2023.

The adults living in the home are Licensee, her spouse, and her adult daughter. All adults have cleared fingerprints. 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.

As a result of this inspection, three Type A were cited. Exit interview conducted and report was reviewed with Licensee Ana Karina Reynoso Ortega. A notice of site visit has been issued and must remain posted for 30 days.

LPA Samantha Yip and Ashley Lopez informed Licensee, Ana Karina Reynoso Ortega, that this report dated 03/30/2023 documents three Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Licensee, Ana, to provide a copy of this licensing report dated 03/30/2023 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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Document Has Been Signed on 03/30/2023 06:54 PM - It Cannot Be Edited


Created By: Samantha Yip On 03/30/2023 at 03:59 PM
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: REYNOSO, ANA KARINA
FACILITY NUMBER: 434416762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which posed an immediate health, safety or personal rights risk to persons in care. There were two sheds in the backyard, which were not locked. There were cleaning supplies, insect spray, and a saw inside.
POC Due Date: 03/31/2023
Plan of Correction
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Deficiency corrected during today's inspection. Licensee locked the shed during today's inspection.
Type A
Section Cited
CCR
102416.5(d)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Upon arrival of today's inspection, Assistant was alone with 11 children.
POC Due Date: 03/31/2023
Plan of Correction
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By POC 03/31/2023, Licensee stated that she will submit a written plan on how she will ensure that the ratio is maintained at all time.
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


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Document Has Been Signed on 03/30/2023 06:54 PM - It Cannot Be Edited


Created By: Samantha Yip On 03/30/2023 at 03:59 PM
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: REYNOSO, ANA KARINA
FACILITY NUMBER: 434416762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Upon arrival, Assistant was alone with 11 children.
POC Due Date: 03/31/2023
Plan of Correction
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By POC 03/31/2023, Licensee will submit plan to ensure that she within ratio and following the capacity if she or her assistant is not present.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


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