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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416851
Report Date: 11/13/2023
Date Signed: 11/13/2023 11:29:53 AM

Document Has Been Signed on 11/13/2023 11:29 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:FLORES, LORNAFACILITY NUMBER:
434416851
ADMINISTRATOR:LORNA FLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 518-9638
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 14TOTAL ENROLLED CHILDREN: 1CENSUS: 1DATE:
11/13/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Lorna FloresTIME COMPLETED:
11:45 AM
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On November 13, 2023 at 8:59 AM, Licensing Program Analyst (LPA) Marilou Monico conducted an announced Prelicensing Inspection. LPA met with Applicant, Lorna Flores, and Applicant's adult friend, Yi "Wendy" Wang and explained the purpose of today's visit. LPA observed an infant in the home. Applicant states that she is currently caring for one child from one family. Applicant states that she is the only adult residing in the home. The home is a one-storey with three bedrooms and two baths. Applicant submitted an application for a large family child care home and fire clearance was granted on 10/26/23.

Days and hours of operation will be Monday - Friday from 7:30 AM to 5:30 PM. Applicant has completed the Preventative Health and Safety Training including Nutrition and Lead Poisoning Prevention and a copy of the certification is on file. Applicant's CPR and First Aid certifications are current and expire on 08/27/25. Applicant completed the Mandated Reporter Training on 09/25/23. Applicant's immunizations in measles, pertussis, and flu are on file. Applicant states that she will use the Affidavit Regarding Liability Insurance (LIC 282) to inform parents that she does not carry daycare insurance.

The Applicant provided proof of control of property. Because the Applicant leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC 9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed barricaded/gated kitchen, covered fireplace, fully charged 3A40BC fire extinguisher, functioning smoke and carbon monoxide detectors. Off limit areas inside the home: master bedroom. The home is clean and orderly, with heating and ventilation for safety and comfort. There is sufficient toys, supplies, and equipment for the day care children. Applicant states that there are no weapons in the home. Off limit areas outside the home: garage, areas outside the lawn, and back area of the garage. There were no bodies of water observed.

Forms of discipline to be used by Applicant: redirection and talking to children. Cleaning products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.
Continuation on next pages:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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: FLORES, LORNA
FACILITY NUMBER: 434416851
VISIT DATE: 11/13/2023
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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. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

Applicant, Lorna Flores, 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, 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 requirements of Assembly Bill (AB) 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA 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 discussed the safe sleep regulations with applicant 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 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.

LPA reviewed with applicant 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. Entrance Checklist was provided to the applicant.

Continuation on next page:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
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: FLORES, LORNA
FACILITY NUMBER: 434416851
VISIT DATE: 11/13/2023
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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.

On this date, October 13 2023, the California Attorney General - Megan's Law website was searched for information on sex offenders required to register with local law enforcement under California Megan's Law. No registered sex offenders found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, 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.

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, Lorna Flores.

A license for a Large Family Child Care Home will be granted upon completion of the following:
1) Submit photo showing that the area between the garage and play area is gated/barricaded.
2) Office meeting at the San Jose Regional Office is scheduled on November 20, 2023 at 9:00 AM.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC809 (FAS) - (06/04)
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