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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415239
Report Date: 08/19/2021
Date Signed: 08/19/2021 03:03:40 PM

Document Has Been Signed on 08/19/2021 03:03 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:CHAVEZ, CARMENFACILITY NUMBER:
444415239
ADMINISTRATOR:CHAVEZ, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 345-7762
CITY:FREEDOMSTATE: CAZIP CODE:
95019
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Carmen ChavezTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo met with licensee Carmen Chavez for an unannounced annual required inspection and explained the nature of today’s visit to her. Present were 7 children of which 6 are preschoolers and .one is an infant. Present was Licensee's helper Melania. The adults living in the home are Licensee, her husband J. Guadalupe, her adult children Hector, Dorian, and Carmen, and sister Ilda. Days and hours of operation are Monday through Friday, 6:00 am to 6:00 PM.

LPA toured the inside and outside of the home. LPA observed no fireplace and no wall heaters. LPA observed barricaded stairs. Off limits indoor: Second floor, kitchen, and the attached garage. There are no bodies of water or firearms/weapons in the home. LPA observed a 3A40BC fire extinguisher that was last serviced on 4/15/21. Smoke detector and Carbon Monoxide detectors are operable. Home is clean and orderly with heating and ventilation for safety and comfort. LPA observed sufficient materials, toys, and play equipment for the children in care. Each child has safe healthful, and comfortable accommodations, furnishings, and equipment. Telephone is in working order. Medicines, poisons and cleaning supplies are inaccessible to the children. Backyard is fenced. Off limits outdoor: Garage. LPA reminded licensee that she can only have 14 children according to her license, and a helper must be present. Licensee understands that without a helper her capacity is reduced to a small license maximum 8. Licensee understands that ratio (age of the children) must be observed for both sizes. Children were supervised on the visit. LPA observed in the helper file proof of TB negative test, SB 792 requirements, AB1207 proof of training on 8/15/21, and pediatric CPR card expiring on 8/07/23. Licensee stated that she does not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and they must follow all CA rules pertaining to the transportation of children.
A listing of staff criminal record clearances associated to this facility in the Licensing Information System (LIS) on 8/13/21 was reviewed; and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions.
Report dated 8/19/21 continues on page 2.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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: CHAVEZ, CARMEN
FACILITY NUMBER: 444415239
VISIT DATE: 08/19/2021
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Report dated 8/19/21 continues from page 1.

LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100 per person per day, minimum of $100 to a maximum of $500 per person for an initial violation, and a minimum of $100 to a maximum of $3000 per person for any subsequent violation within a 12-month period. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately remove the individual and prevent them from returning to the home or having contact with children in care.

LPA obtained a copy of the children's roster and observed the fire and disaster drill was documented on 8/10/21. LPA reviewed four children's files and observed that parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification and emergency information forms are in each file. Licensee has completed the Mandated Reporter training on 12/18/20. Licensee has a Pediatric CPR/ first Aid expiring on 3/12/23.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. Licensee has previously submitted an IMS plan to the Department.


LPA advised licensee of the new regulations on Safe sleep for infant children. and provided licensee with form LIC9227. LPA referred the Licensee to the Department website: www.ccld.ca.gov for additional information.
LPA provided licensee with the Lead Poisoning Facts sheet.

No deficiencies were cited today. An exit interview was conducted with Licensee in Spanish.
Notice of site visit was printed and licensee was instructed to keep it posted by the entrance of the facility for 30 days
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC809 (FAS) - (06/04)
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