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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417657
Report Date: 10/30/2023
Date Signed: 10/30/2023 12:02:08 PM

Document Has Been Signed on 10/30/2023 12:02 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CARRILLO H., TANYAFACILITY NUMBER:
434417657
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
10/30/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Tanya Carrillo HernandezTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Teodoro Trujillo met with Applicant, Tanya Carrillo Hernandez, to conduct an announced pre-licensing site visit. LPA was granted access to the home by the Applicant. No children were present in the home during today's inspection. The Applicant and her spouse, Henry and adult cousin Ricardo are the adults residing in the home. There are no minor children residing in the home.

Days and hours of operation will be Monday - Friday from 7:00 AM to 5:00 PM. Applicant completed her Preventative Health and Safety Child Care Training on 03/09/2019 and a copy of the certification is on file. Applicants CPR and First Aid certifications are current and expire on 05/14/24. Copies of both certifications are on file. Applicant completed the Mandated Reporter Training for Child Care Workers on 08/28/23, and a copy of the certification is on file. A copy of current TB test, flu, Mmr, and Tdap vaccinations for the Applicant are on file. Applicant rents the home and a copy of the lease agreement verifying control of property and Owner/Landlord Notification (LIC 9151) and Landlord Consent (LIC 9149) form are on file. Applicant understands that she cannot care of more than 8 children at any time. Applicant does not have liability insurance and will issue Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282).

LPA toured the indoor and outdoor areas of the home with the Applicant during today's inspection. The Applicant's home is single story home and LPA observed no stairs during today's inspection. LPA observed a swimming pool surrounded with a metal fence in front of the kitchen area, and 5 ft. fence with a self-latching door and self-latching device 8” from the top of gate in the West area of the pool, 5-foot mesh fence facing the south pool area has a self-latching door, with self-latching mechanism 19 inches from top of fence. There are no wall heater units in the home. Applicant states that she will operate the day care in the following areas: Living room, dining room and hallway bathroom. Off limit areas inside the home: bedroom 1, bedroom 2, bedroom 3 and bedroom 4 with master bathroom, kitchen and attached garage. Off limit areas outside the home: locked storage room, fenced off swimming pool, side area leading to swimming pool, kitchen back yard porch area.

The home is clean, orderly, (including heating/air conditioning), and ventilation for safety & comfort. There is sufficient toys, supplies, and equipment for the day care children both indoors/outdoors. LPA observed a fully charged fire extinguisher (3A40BC) that has not been serviced, applicant purchased on 2/27/2022 and working smoke and carbon monoxide detectors, fenced backyard. Applicant states that she does not have any weapons/ammunition in the home.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CARRILLO H., TANYA
FACILITY NUMBER: 434417657
VISIT DATE: 10/30/2023
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Applicant states her cat is vaccinated. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. Applicant states that poisons are stored in locked garage. LPA reminded Applicants that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes. Applicant states that she will not administer any medication to the children at this time. Applicant states that a child will be isolated in the dining room area if necessary due to illness or communicable disease. Applicant has a First Aid kit in the home.

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.

Tanya Carillo Hernandez, 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, 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 discussed the requirements of 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 provided and reviewed 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. LPA also discussed the importance of maintaining records for any person/assistant providing care to the children and children in the home under 10 years of age.

LPA provided and 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

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:
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
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CARRILLO H., TANYA
FACILITY NUMBER: 434417657
VISIT DATE: 10/30/2023
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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.

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. LPA provided the applicant the Department website: www.ccld.ca.gov

Exit interview conducted and report was reviewed with the Applicant, Tanya Carrillo Hernandez, and LPA advised her that a small Family Child Care Home License is pending approval by Licensing Program Manager.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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