434417646-5-18-2023-07-CC-DVIA-CRXTU3-20230518150139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417646
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:01:47 PM

Document Has Been Signed on 05/18/2023 03:01 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:	MORA, NANCY		FACILITY NUMBER:	434417646
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	05/18/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Nancy Mora		TIME COMPLETED:	03:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Deanna Villagrana met with applicant Nancy Mora to conduct an announced change of location inspection to the home today. Applicant's previous license is 434416050 located at 200 E. Tenth St. #252 Gilroy, Ca 95020. The adults that reside in the home are the Applicant and her husband, with two children ages ten and eight years old. Days and hours of operation will be Monday - Friday from 6:00 AM to 6:00 PM. Applicant has completed her Preventative Health and Safety Child Care Training on 12/03/2021 and a copy of the certification is in file. Applicant's CPR and First Aid certifications are current and expire on 11/20/2023. Applicant completed Mandated Reporter training on 11/21/2021 and has immunization records on file against pertussis, measles and influenza. Applicant rents the home. LPA reminded the Applicant that she cannot care for more than six children unless she obtains the Owner/Landlord consent for day care. Applicant does not have liability insurance and will issue affidavit regarding liability insurance for FCCH. LPA toured the indoor and outdoor areas during today's visit. The home is one of the units of a duplex. There are no stairs or fireplace in the home. Off limit areas inside the home: three bedrooms and laundry room that also has a bathroom in it. LPA observed a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide, fenced backyard, and no bodies of water. Off limit areas outdoor: right side yard, detached garage and area fenced off behind the garage. Applicant states that there are no weapons in the home. 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. Applicant has one dog that stays in an off limits room and is vaccinated. A review of staff records on 05/09/2023 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Nancy Mora was reminded that all adults 18 and over living in the home, persons who provide care and supervision

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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: MORA, NANCY	FACILITY NUMBER: 434417646
	VISIT DATE: 05/18/2023

NARRATIVE

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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 reviewed with Nancy Mora 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. Forms of discipline used by Applicant: talking to children and redirection. 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.

LPA discussed the safe sleep regulations with Nancy Mora 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 Nancy Mora 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 the requirements of AB 633 with the Applicant and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Applicant understands the requirements. LPA also 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. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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: MORA, NANCY	FACILITY NUMBER: 434417646
	VISIT DATE: 05/18/2023

NARRATIVE

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102417. 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. SB 792 Immunization Requirements was also discussed. Applicant's immunization records are on file.

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 Nancy Mora. Applicant was informed Owner/Landlord Notification form (LIC 9151) is required and approval for a small family home day care license is approved pending managers approval.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

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