434417688-8-28-2023-07-CC-TTRO-CV5R8K-20230828124804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417688
Report Date: 08/28/2023
Date Signed: 08/28/2023 12:48:18 PM

Document Has Been Signed on 08/28/2023 12:48 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:	DIAZ, ELIZABETH		FACILITY NUMBER:	434417688
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	08/28/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Elizabeth Diaz		TIME COMPLETED:	01:00 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	LPA Teodoro Trujillo met with applicant, Elizabeth Diaz, and conducted a pre-licensing inspection for location change and increase in capacity at this facility. Applicant's current license is #434413663 located at 3790 Dottielyn Ave, San Jose, CA 95111. The adults that reside in this home are Applicant and her husband with a 1, 6 and 13 year-old children. Days and hours of operation will be Monday to Friday from 6:00 am to 5:30 pm. Applicant has completed her Preventative Health and Safety Child Care Training with the lead poisoning prevention module and a copy of certifications verifying completion is in file. Applicant's CPR and First Aid certifications are current and expire on 09/24/24. Applicant rents the home and the Owner/Landlord Notification form (LIC 9151) and Property Owner Landlord Consent (LIC 9149) is on file. Applicant has liability insurance for her current license, and it will be renewed under this facility once licensed. Applicant understands that if she decides not to carry liability insurance in the future, she will have parent/authorized representative sign the Affidavit Regarding Liability Insurance for FCCH form (LIC 282). LPA toured the indoor and outdoor areas during today's visit. There are no stairs in the home. Off limit areas inside the home: all bedrooms and attached garage. Facility Evaluation Report dated 08/28/23 to be continued on next page:Pg 1 of 3

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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: DIAZ, ELIZABETH	FACILITY NUMBER: 434417688
	VISIT DATE: 08/28/2023

NARRATIVE

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Facility Evaluation Report dated 08/28/23 to be continued from previous page:
LPA observed a fully charged 3A40BC fire extinguisher, working smoke and carbon monoxide detector. LPA observed a fenced backyard, and no bodies of water. Off limit areas outside the home: the gated off limit area. 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.

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.

Forms of discipline used by Applicant: will use thinking corner method and talk with them.

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.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: DIAZ, ELIZABETH	FACILITY NUMBER: 434417688
	VISIT DATE: 08/28/2023

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Facility Evaluation Report dated 08/28/23 to be continued from previous page:
Department website: www.ccld.ca.gov provided to Applicant. Website for provider resources: https://cdss.ca.gov/inforesources/Child-Care-Licensing. Periodic information releases accessible by signing up at: www.myccl.ca.gov.

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, and an ongoing $100 per day per violation continues until the violation(s) is corrected.

AB792 Immunization Requirements was discussed. LPA observed the required immunization records for Applicant and her husband were in file.

LPA reviewed infants safe sleep policies with Applicant.

Website to complete training: https://mandatedreporterca.com. A link to the alternate trainers approved to provide mandated reporter training:
https://www.cdss.ca.gov/Portals/9/CCLD/CCP%20Documents/Approved%20Mandated%20Reporter%20Trainings.pdf. Applicant completed her training on 03/27/2022. Applicant understands that the training is to be completed every two years.

Fire clearance was granted on 08/17/23 by the San Jose Fire Department. License for a Large Family Child Care Home is approved pending Licensing Program Manager approval.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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