444406150-4-26-2022-07-CC-EBEN-CDUNRT-20220426104200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444406150
Report Date: 04/21/2022
Date Signed: 04/26/2022 10:42:06 AM

Document Has Been Signed on 04/26/2022 10:42 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	ZAMUDIO, VELINA		FACILITY NUMBER:	444406150
ADMINISTRATOR:	ZAMUDIO, VELINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 722-3186
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 1	DATE:	04/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Velina Zamudio		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	Licensing Program Analyst (LPA), Elizabeth Berumen conducted a 1 year required inspection. LPA met with Licensee, Velina Zamudio and her adult daughter, Maria Carmen Zamudio. One infant day care child was present and Licensee's adult granddaughter (Aaliyah Farfan). Licensee states there are 3 adults living in the home; Licensee, daughter and granddaughter. Licensee's two minor grandchildren live in the home (ages 17 and 13). A review of staff records during today's visit indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record an child abuse index clearances or exemptions. LPA inspected the indoor and outdoor areas of the home. Off limit areas inside the home are five bedrooms, bathroom #2 and living room. Off-limit areas outside are two storage rooms and small detached studio/ garage. The studio is used as a secondary kitchen and Licensee states it is not being rented to anyone. The backyard is fenced. LPA inspected the studio/garage during today's inspection; Licensee states that she was planning to use it for day care. LPA explained the requirement and informed that a fire inspection approval is required before use. LPA observed that the studio has a small kitchen and bathroom/ the garage door is still on garage. This studio is not approved for day care use. LPA observed a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and barricaded fire place. Velina has a pet dog and vaccinations were reviewed today. Cleaning products, sharp objects, medication and other similar items are stored inaccessible to children. Licensee states that there are no weapons in the home. LPA observed a current roster. LPA reviewed fire disaster drill log; last practiced drill was 10/4/21. LPA reminded Licensee and assistant that drills are to be conducted once every 6 months and documented. LPA reviewed one children file during today's inspection file is missing Infant sleeping plan and Parents rights (LIC995). Licensee, Velina Zamudio and her Assistant completed the mandated child abuse reporting training. Licensee's Mandated Reporter Training expires on 06/12/2022. Licensee and her helper have immunization against measles and pertussis. Both have signed declarations dated this year (2022) declining the influenza vaccine.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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 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: ZAMUDIO, VELINA	FACILITY NUMBER: 444406150
	VISIT DATE: 04/21/2022

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

Supervision of children was discussed with the 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/ratio options and she understands that she cannot have more than 14 children present in the home without two qualified adults present. Licensee states that does not transport any day care children. Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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.

LPA discussed the safe sleep regulations with the Licensee 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 the 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.

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, Velina Zamudio. Deficiency cited on 809D.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 04/26/2022 10:42 AM - It Cannot Be Edited

Created By: Elizabeth Berumen On 04/21/2022 at 12:37 PM

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: ZAMUDIO, VELINA	FACILITY NUMBER: 444406150
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)(2)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. Infant enrolled in family child care home is missing the Individual Sleeping Plan LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2022
	Plan of Correction
1 2 3 4	Licensee and Assistant, Maria Del Carmen Zamudio agree to submit the LIC 9227.

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:

Mary Segura

LICENSING EVALUATOR NAME:

Elizabeth Berumen

LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3