434417907-11-6-2025-07-CC-LFII-DN6RWE-20251106122301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417907
Report Date: 11/06/2025
Date Signed: 11/06/2025 12:23:21 PM

Document Has Been Signed on 11/06/2025 12:23 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, VIVIANA		FACILITY NUMBER:	434417907
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 6	CENSUS: 4	DATE:	11/06/2025
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Rodriguez, Viviana		TIME VISIT/ INSPECTION COMPLETED:	12:30 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 11/6/2025, Licensing Program Analyst (LPA) Liridon Fici- Doni conducted an unannounced Pre-Licensing inspection. LPA met with Licensee, Rodriguez, Viviana and explained the reason for the inspection. The purpose of this inspection is Licensee applied for a change of capacity from a small Family Child Care Home (FCCH) to a large FCCH. Licensee has at least one year of experience as a licensee of a small FCCH to apply for a large FCCH. A fire clearance was granted on 10/15/2025. There were four (4) children and three (3) staff present during today's inspection. There is an area to post required postings, such as license and notification of parent's rights. The hours of operation are Monday through Thursday from 7:00AM to 4:45PM and Fridays from 7:00AM to 3:00PM. Licensee does have liability insurance. The department received a copy of the Licensee's mortgage statement, which is on file. LPA toured the inside and outside of the home with Licensee. The off-limit areas inside of the home include: Bedrooms and garage. There are no off-limits to the outside. Licensee stated children are able to use the front and back yard of the home to play; Licensee mentioned there shall always be staff supervision at all times. The backyard in also fenced and secured for children's safety. Disinfectant, cleaning supplies, and other items that could pose a risk to children were inaccessible and locked up. There are toys and equipment for children to play with. There is a fully charged fire extinguisher, along with working smoke and carbon monoxide detectors that are interconnected. The last fire/disaster drill was conducted on 8/6/2025. Licensee stated that there are no weapons, such as firearms, stored in the home. LPA did not observe any bodies of water during inspection. Continued on Page 2...

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Liridon Fici
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: RODRIGUEZ, VIVIANA	FACILITY NUMBER: 434417907
	VISIT DATE: 11/06/2025

NARRATIVE

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LPA reminded Licensee and she understands that she needs to supervise children when using the back and front yard at all times. LPA reminded Licensee to check all plastic play structures for any cracks or/and damages that can injury a child in care. Licensee mentioned to LPA that she does not transport children at all, and understands no child shall be left in a car unattended for any reason.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep website athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee 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 informed Licensee that Infants 12 months (1 Year old) and under will use the Lic9227 (Individual Infant Sleep Plan) and conduct 15-minute sleep logs, and Infants 1 year old and above will continue the 15-minute sleep log until age 2 years old.

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: https://www.ada.gov/resources/child-care-centers/. Licensee stated she does not accept children who need medication; all medication shall be taken at the child's home before coming to day care.

During record review, Licensee and Staff file were reviewed for the following records...

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Liridon Fici
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025

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: RODRIGUEZ, VIVIANA	FACILITY NUMBER: 434417907
	VISIT DATE: 11/06/2025

NARRATIVE

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Employee Rights (LIC9052), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). Licensee has a current Mandated Reporter Training and expires on 8/7/2026. Licensee has current Pediatric CPR/FIRST AID that expires on 6/14/2026. LPA informed Licensee that Mandated reporting and First aid/CPR is mandatory and should be renewed every 2 years.

LPA reminded Licensee when admitting new children into the home, she shall ensure that parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification forms are in each file completed, signed and dated by child's representative. LPA obtained a copy of the facility roster during today's inspection.

LPA discussed with Licensee about the maximum capacity requirement of a Large Family Child Care Home License. The maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home shall be either:
(1) 12 children, no more than four of whom may be infants; or
(2) more than 12 and up to 14 children if at least one child is enrolled in and attending kindergarten or elementary school and a second child is at least six years of age and there are no more than three infants being cared for during any time when more than 12 children are being cared for.

LPA reminded Licensee that when Licensee does not have an assistant, Licensee can only care for up to 8 children at any one time in the home.

Licensee is the only adult living in the home. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Liridon Fici
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: 11/06/2025

NARRATIVE

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During the exit interview, the Licensee, Rodriguez, Viviana, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Licensee was advised that upon review and approval of Licensing Program Manager (LPM), a license for a large Family Child Care Home will be granted and issued.

No deficiencies were issued as a result of this inspection.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and this report was reviewed with the licensee, Rodriguez, Viviana.

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Liridon Fici
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025

LIC809 (FAS) - (06/04)

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