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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444406156
Report Date: 05/25/2022
Date Signed: 05/25/2022 12:16:52 PM

Document Has Been Signed on 05/25/2022 12:16 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:SANDOVAL, VERONICAFACILITY NUMBER:
444406156
ADMINISTRATOR:VERONICA SANDOVALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 228-1035
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
05/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Veronica SandovalTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA), Cortney Nelson, met with Licensee, Veronica Sandoval, and explained purpose of visit. Upon arrival there were 6 children (2 infants/ 4 preschool age), Licensee, and assistant present which is complaint with license ratio and capacity requirements. Three (3) additional school-aged children were picked up during todays inspection.

Upon review of staff files, it was observed that staff present at the facility today are missing required documents in their file. Licensee states that she does not have the updated Mandated Reporter training certificates or other required documents for her staff. LPA advised Licensee that she must maintain required documents for all staff who work with the children at her family day care home.

Deficiencies have been cited as a result of todays inspection, see 809-D.

A NOTICE OF SITE VISIT HAS BEEN ISSUED AND MUST BE POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Licensee, Veronica Sandoval.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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 4
Document Has Been Signed on 05/25/2022 12:16 PM - It Cannot Be Edited


Created By: Cortney Nelson On 05/25/2022 at 10:47 AM
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: SANDOVAL, VERONICA
FACILITY NUMBER: 444406156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2022
Section Cited
HSC
1596.8662(4)(b)(1)

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On or before March 30, 2018 a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training...[and] shall complete renewal mandated reporter training every two years following the date... she completed the initial mandated reporter training.

This requirement was not met as evidenced by:
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Licensee will submit renewed Mandated Reporter certificate for herself and her assistant by 6/8/2022.
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Based on interview and record review, Licensee did not have proof of completion of renewed Mandated Reporter certificate for herself and her assistant which poses a potential risk to the health, safety, and personal rights of children in care.
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Type B
06/08/2022
Section Cited
HSC1597.622(a)(1)

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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if.. she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement was not met as evidenced by:
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Licensee will submit proof of immunizations for her assistant by 6/8/2022.
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Based on interview and record review, Licensee did not have proof of immunizations for her assistant which poses a potential risk to the health, safety, and personal rights of children in care.
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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/25/2022 12:16 PM - It Cannot Be Edited


Created By: Cortney Nelson On 05/25/2022 at 10:59 AM
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: SANDOVAL, VERONICA
FACILITY NUMBER: 444406156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2022
Section Cited
CCR
102416.1(a)

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102416.1 Personnel Records (a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement was not met as evidenced by:
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Licensee will submit required documents for assistant (LIC508, LIC9108, LIC9052) by 6/1/2022 and maintain documents at family day care home.
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Based on record review and interview, Licensee did not maintain required documents for assistant (LIC508, LIC9052, LIC9108) which poses a potential risk to the health, safety, and personal rights of children in care.
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Type B
06/08/2022
Section Cited
CCR102369(b)(9)

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102369 Application for Initial License (b) the applicant shall provide all of the following information... (9) Evidence of a current tuberculosis clearance...for any adult in the home during the time that children are in care.

This requirement was not met as evidenced by:
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Licensee will submit tuberculosis test for her assistant by 6/8/2022.
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Based on record review and interview, Licensee did not have proof of TB test for assistant working with children which poses a potential risk to the health, safety, and personal rights of the children in care.
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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/25/2022 12:16 PM - It Cannot Be Edited


Created By: Cortney Nelson On 05/25/2022 at 11:52 AM
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: SANDOVAL, VERONICA
FACILITY NUMBER: 444406156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2022
Section Cited
HSC
1596.841

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Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.

This requirement was not met as evidenced by:
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Licensee will submit updated roster with all children currently enrolled by 6/1/2022.
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Based on observation, interview, and record review, Licensee did not maintain current roster at her facility with poses a potential risk to the health, safety, and personal rights of children in care.
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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022


LIC809 (FAS) - (06/04)
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