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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417649
Report Date: 10/29/2024
Date Signed: 10/29/2024 11:38:16 AM

Document Has Been Signed on 10/29/2024 11:38 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:CACIOPPO, SORAYAFACILITY NUMBER:
434417649
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 4CENSUS: 4DATE:
10/29/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Soraya CacioppoTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Soraya Cacioppo for an annual/random visit. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's three year old son and three day care infants. One infant was being picked up when LPA arrive. Days and hours of operation are Monday to Friday, 7:30am to 5:30pm. The adults that reside in the home are licensee, her husband, with her ten and three year old sons.

A review of staff records on 10/22/2024 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Soraya Cacioppo 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 toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed two barricaded wall heaters in the home. LPA observed one infant asleep in a play yard and one awake in a play yard in a nap room with the door closed. The door is solid wood with no visibility of children. LPA observed the sleeping infant with a stuffed animal and toy in the play yard with a blanket hung over the play yard. Licensee stated she placed the other infant who was awake and crying in the play yard to sleep. LPA explained licensee could not force children to sleep or stay in a designated sleep area. Licensee stated mother requested child sleep at certain hours. LPA observed infants be placed in feeding chairs with no food and crying. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed cleaning supplies under bathroom sink and kitchen sink accessible to children. The baby gates to make kitchen inaccessible were not closed making the kitchen
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
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: CACIOPPO, SORAYA
FACILITY NUMBER: 434417649
VISIT DATE: 10/29/2024
NARRATIVE
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accessible to children. LPA observed a mop bucket with three inches of water accessible to children in the kitchen. LPA observed a fully charged 1A10BC fire extinguisher. LPA observed a working combo smoke and carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: master bedroom/bath, one bedroom, kitchen and attached garage. Backyard is fenced. Off limits outdoor: right side of home that is fenced off to children and storage. Licensee states there are no animals in the home. LPA observed licensee has a current CPR and First Aid certification expiring 05/04/2026 and completed Mandated Reporter training on 01/30/2024.

LPA observed a roster of the children was not complete and only listed names of children and phone number. Licensee stated she did not have a fire and disaster drill log and only has conducted a drill one time since she's been licensed. LPA reviewed four children's files. Child 1 does not have immunization records. Child 2 is missing LIC995 and immunization records need to be updated. Licensee states day care is not insured. LPa observed LIC282 in children's files. LPA discussed SB792 Immunization Requirements and observed licensee has immunization records on file.



Supervision of children was discussed with licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than eight children in the home at any time. Licensee states she cares for four infants at this time. LPA explained when her child is present, that she may not have all four infants present. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed the safe sleep regulations with licensee Soraya Cacioppo 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 Soraya Cacioppo 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 Zero Tolerance related regulations with licensee Soraya Cacioppo and was advised of the assessment of $500 immediate civil penalty and an ongoing $100 per
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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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: CACIOPPO, SORAYA
FACILITY NUMBER: 434417649
VISIT DATE: 10/29/2024
NARRATIVE
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day per violation 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 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

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.

Exit interview conducted and report was reviewed with the licensee Soraya Cacioppo. During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPA Deanna Villagrana informed licensee Soraya Cacioppo that this report dated 10/29/2024 document(s) 4 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Deanna Villagrana informed the licensee Soraya Cacioppo to provide a copy of this licensing report dated 10/29/2024 that documents any Type A citation(s) 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.

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.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 10/29/2024 11:38 AM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/29/2024 at 10:43 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: CACIOPPO, SORAYA
FACILITY NUMBER: 434417649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above. LPA observed the sleeping infant with a stuffed animal and toy in the play yard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee removed items during visit. Licensee will submit a statement stating she has read Safe Sleep Regulations to CCLD by POC date.
Type A
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

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. LPA observed one infant asleep in a play yard and one awake in a play yard in a nap room with the door closed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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2
3
4
Licensee will submit a statement stating she has read Safe Sleep Regulations to CCLD by POC date.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 10/29/2024 11:38 AM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/29/2024 at 10:43 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: CACIOPPO, SORAYA
FACILITY NUMBER: 434417649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

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. LPA observed infants be placed in feeding chairs with no food and crying which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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LPA explained to licensee that chairs are only used for feeding and may not detain children. Licensee removed infants during visit. Deficiency cleared today.
Type A
Section Cited
CCR
102417(g)(5)


This requirement is not met as evidenced by: All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a mop bucket with three inches of water accessible to children in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
1
2
3
4
Licensee removed water from bucket during visit. Deficiency cleared today.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 10/29/2024 11:38 AM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/29/2024 at 10:43 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: CACIOPPO, SORAYA
FACILITY NUMBER: 434417649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed a fully charged 1A10BC fire extinguisher which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee will submit a photo of a 2A10BC fire extinguisher or larger to CCLD by POC date.
Type B
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed cleaning supplies under bathroom sink and kitchen sink accessible to children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
1
2
3
4
Licensee will remove items and make inaccessible to children. Licensee will submit photos to CCLD by POC date.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 10/29/2024 11:38 AM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/29/2024 at 10:43 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: CACIOPPO, SORAYA
FACILITY NUMBER: 434417649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

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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2
3
4
Based on interview, the licensee did not comply with the section cited above. Licensee stated she did not have a fire and disaster drill log and only has conducted a drill one time since she's been licensed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Licensee conduct a fire and disaster drill and submit a copy of the log to CCLD by POC date.
Type B
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed the sleeping infant with a blanket hung over the play yard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Licensee will submit a statement stating she has read Safe Sleep Regulations to CCLD by POC date.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 10/29/2024 11:38 AM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/29/2024 at 10:43 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: CACIOPPO, SORAYA
FACILITY NUMBER: 434417649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(e)
Infant Safe Sleep
No infant shall be forced to sleep, to stay awake, or to stay in the designated sleeping area.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above. Licensee stated she placed the other infant who was awake and crying in the play yard to sleep which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Licensee will submit a statement stating she has read Safe Sleep Regulations to CCLD by POC date.
Type B
Section Cited
CCR
102425(j)(5)(A)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. The provider shall be able to visually observe the infant without moving the door.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed one infant asleep in a play yard and one awake in a play yard in a nap room with the door closed. The door is solid wood with no visibility of children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Licensee will submit a statement stating she has read Safe Sleep Regulations to CCLD by POC date.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 10/29/2024 11:38 AM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/29/2024 at 10:43 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: CACIOPPO, SORAYA
FACILITY NUMBER: 434417649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Child 2's immunization records need to be updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Licensee will submit updated immunization records for child 2 to CCLD by POC date.
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed a roster of the children was not complete and only listed names of children and phone number which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
1
2
3
4
Licensee completed roster during visit. Deficiency cleared today.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 10/29/2024 11:38 AM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/29/2024 at 10:43 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: CACIOPPO, SORAYA
FACILITY NUMBER: 434417649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Child 2 is missing LIC995 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Licensee will submit LIC995 for child 2 to CCLD by POC date.

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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2024 11:38 AM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/29/2024 at 11:09 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: CACIOPPO, SORAYA
FACILITY NUMBER: 434417649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)


This requirement is not met as evidenced by: Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Child 1 does not have immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Licensee will submit immunization records for child 1 to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Susy Cervantes
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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