<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417907
Report Date: 08/16/2024
Date Signed: 08/16/2024 02:31:13 PM

Document Has Been Signed on 08/16/2024 02:31 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:RODRIGUEZ, VIVIANAFACILITY NUMBER:
434417907
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Rodriguez, VivianaTIME VISIT/
INSPECTION COMPLETED:
02:35 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
On 8/16/24, at 10:15 AM, Licensing Program Analyst (LPA), Liridon Fici (Doni) met with Applicant, Rodriguez, Viviana, for an announced pre-licensing inspection. The purpose of today's inspection is to ensure the home is in compliance with Title 22 California Code of Regulations. Upon arrival, LPA was admitted into the home by the Applicant and toured inside and outside during todays inspection.

The Applicant states that adults, over the age of 18, residing in the home is her spouse and herself. The Applicant has four (4) minor children living in the home. LPA advised that children living in the home will be included in the home ratio and capacity until they turn 10 years of age. The hours of operation for the family child care home (FCCH) will be Monday - Friday, 7:00AM - 5:30PM and the Applicant is planning to offer care for children ages 0 months to 12 years old. The Applicant has submitted a mortgage statement for the home and does not currently have liability insurance for the day care. LPA advised the Applicant to provide parents with Affidavit Regarding Liability Insurance (LIC282) upon registration until liability insurance is purchased in the future.

The Applicant 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 toured inside the home and observed sufficient materials, play equipment tables, and a baby changing station for the day care children. Off limits inside the home include: All bedrooms, and master bathroom. LPA advised if there are changes to the on/off limits of the home to submit an updated facility sketch (LIC999A) to the San Jose Regional Office...



Continued on Page 2...
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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 4
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: RODRIGUEZ, VIVIANA
FACILITY NUMBER: 434417907
VISIT DATE: 08/16/2024
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
26
27
28
29
30
31
32
There is a working land line and telephone (cell phone) at the FCCH. The Applicant currently has one crib and zero mats for children's napping. LPA advised that mattress sheets should be changed between infants, if the crib is shared, and infant sheets shall be washed daily.

The Applicant states that she might provide medication and Incidental Medical Services to children. The Applicant states that all food/formula will be provided by the parents of children enrolled and Licensee will prepare and warm food as needed at her home for children. Children will bring water in water bottles if needed. The Applicant has one high chair available for feeding infants. LPA observed kitchen knives properly stored inaccessible to children. LPA advised reviewing storage of materials in kitchen/bathroom cabinets if the restroom is needed by older children in care. There are no firearms in the home.

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

The Applicant is planning to care for infants and has a baby changing pad, waste bin with a tight-fitting lid, and proper storage for diapers and wipes. There is a sink that is easily accessible in the kitchen for use, if needed.

The Applicant states that she is currently planning to use any outdoor space for caring for children. LPA advised that if she plans to use outdoor space in the future, to submit an updated facility sketch (LIC999A).

LPA observed fully charged 2A10BC fire extinguisher, functioning smoke and carbon monoxide detector that are interconnected. LPA advised completing annual maintenance for the fire extinguisher. The Applicant was provided fire/emergency disaster drill log and was advised drills should be completed every 6 months.

The Applicant states that for discipline of the children, she will use redirection and 1:1 time with the child as needed. LPA advised that if utilized, the recommended duration for "time out" is 1 minute per year of age for the child...
Continued on Page 3...
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: RODRIGUEZ, VIVIANA
FACILITY NUMBER: 434417907
VISIT DATE: 08/16/2024
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
26
27
28
29
30
31
32
The Applicant understands that children's personal rights should not be violated; including no corporal punishment. Children should not be left for extended periods of time in furniture such as a high chair or play pen.

LPA discussed isolation of sick children with the Applicant and she states that if a child were to start feeling sick at her home that she would isolate the child with a napping mat, until the parent/guardian arrives to pick-up. LPA discussed isolation strategies, such as using a baby gate, and utilizing the restroom if the child's symptoms need close restroom access. LPA observed the Applicant has a first-aid kit, and thermometer, available in her home.

LPA additionally discussed supervision of children, unusual incidents (LIC624B), and requirements for additional staff/ adults living in the home. The Applicant states that she does not plan to transport children. The Applicant additionally understands that she must be home at least 80% of the time FCCH is open.

LPA reviewed small family child care home capacity requirements with the Applicant and provided copy of 102416.5 Staffing Ratio and Capacity from California Code of Regulations. The Applicant is not planning to care for more than six children at any time. There should never be more than four infants, children under two years of age, present at the FCCH.

LPA reviewed with the Applicant 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. LPA discussed required postings with Applicant and provided copies of Parents Rights bulletin (PUB394) and Earthquake Preparedness Checklist (LIC9148). LPA discussed Provider Information Notices (PINs). LPA additionally reviewed CCLD website and online annual fee payment.

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.

Continued on Page 4...

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: RODRIGUEZ, VIVIANA
FACILITY NUMBER: 434417907
VISIT DATE: 08/16/2024
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
26
27
28
29
30
31
32
LPA discussed the safe sleep regulations with the Applicant and provided 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.

The Applicant was informed of the MyChildCarePlan.org website; 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.

Exit interview conducted and report was reviewed and provided to the Applicant, Rodriguez, Viviana

LPA advised the Applicant that a small FCCH license will be issued pending manager review and approval.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4