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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415565
Report Date: 03/24/2025
Date Signed: 03/24/2025 03:24:07 PM

Document Has Been Signed on 03/24/2025 03:24 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:PEREZ, MARTHAFACILITY NUMBER:
444415565
ADMINISTRATOR/
DIRECTOR:
PEREZ, MARTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 227-4727
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 6DATE:
03/24/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Martha PerezTIME VISIT/
INSPECTION COMPLETED:
03:35 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 March 24, 2025, Licensing Program Analyst (LPA) Darnella Barnes conducted an unannounced annual random inspection. The purpose was explained to the licensee, who granted access. and received the Entrance Checklist (LIC 126).

The facility operates Monday through Friday 6:00am - 6:00pm. Required postings were visible, and the last fire/disaster drill was on 3/11/25, The licensee was reminded of the six-month drill and documentation requirement.

Licensee, one Assistant, 1 infant, 4 preschooler, were present meeting the capacity ratio requirement. LPA observed the licensee providing care in a safe and comfortable environment, ensuring children were treated appropriately and free form any form of punishment or mistreatment. Licensee was reminded of the capacity ratio rules, supervision requirements, reporting obligations, and that children’s rights cannot be waived.

All adults 18 and older associated with the facility, including residents and volunteers, have fingerprint clearances.

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 Childcare 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.

A child showing signs of illness must be separated from others until the nature of the illness is determined. If it is communicable, the child remains separated until no longer infectious or until a parent picks them up..

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
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 6
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: PEREZ, MARTHA
FACILITY NUMBER: 444415565
VISIT DATE: 03/24/2025
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
PAGE 2

LPA toured the facility, indoor off-limit areas include garage and all of second floor. Licensee has a gate at the bottom to prevent access for children. . . It was nap time, LPA observed a blanket near a play yard with a child sleeping in play yard, LPA advised licensee that blankets(loose articles) are not allowed. Licensee removed the blanket immediately from the area. Also, although there were no loose articles or objects, bumper pads, no hanging objects, or pacifiers, play yard was missing a firm mattresses and a fitted sheet. The home was clean, well ventilated, and stocked with safe, age-appropriate toys. A fully charged 3A-40B-C fire extinguisher (last serviced 2/9/25) was present, along with working smoke and carbon monoxide detectors, and an operating telephone. Hazardous items, including poisonous detergents, cleaning compounds, and medicines were stored out of children’s reach. Smoking, baby walkers, bouncers, jumpers, and similar items are prohibited in the day-care settings. Licensee confirmed there were no guns or ammunition on the premises. The licensee was reminded to notify licensing before making any changes to the house or yard.

Home is on a hill. Outdoor off limit areas include the lower part of the hill. Outdoor play area is fenced and is filled with age-appropriate toys for the children; blocks, manipulative toys, art supplies, sand box.

Licensee CPR/First Aid expires 3/10/27 and mandatory training expires: 8/2/26.Assistant CPR/First Aid expires 3/10/27 and mandatory training expires: 8/2/26. The preventive health certification are on file. LPA reminded the licensee of the two-year renewal requirement.

The facility roster and five children’s file were reviewed, confirming all required forms were complete, including the affidavit regarding liability insurance (LIC 282). The licensee confirmed no liability insurance at this time.

The licensee does transport children and Licensee has valid driver’s license to transport children. LPA also reminded the licensee that children cannot be left unattended in vehicles and that car seats and booster seats must be available for safe transportation

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: PEREZ, MARTHA
FACILITY NUMBER: 444415565
VISIT DATE: 03/24/2025
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
PAGE 3

Safe Sleep Information was provided, and licensee was reminded that an Individual Infant Sleeping Plan (LIC 9227) is a required for each infant up to 12 months old, with nap checks documented until age two. Cribs and play yards must be free of loose items, bumper pads, and hanging objects and mattresses must be firm, properly fitted, and have fitted sheets.

LPA discussed the safe sleep regulations with 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 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.

Licensee was reminded 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 platforms. To receive important licensed related information to licensed facilities, inspection 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.



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)/ (8004314-0383 (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 was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California. Car seats and booster seats must be available for safe transportation.
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: PEREZ, MARTHA
FACILITY NUMBER: 444415565
VISIT DATE: 03/24/2025
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
FINAL PAGE

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please inspection the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

During the exit interview, the Licensee confirmed no Registered Sex Offenders reside at the facility. The LPA completed the RSO profile in FAS on 3/3/25. A search of the California Attorney General-Megan’s Law website found no registered sex offenders at the facility address.

During today’s inspection, (2) “Type B” deficiency was identified on attached 809-D. Appeal rights provided.

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

Exit interview conducted and report was reviewed with the Licensee
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/24/2025 03:24 PM - It Cannot Be Edited


Created By: Darnella Barnes On 03/24/2025 at 02:51 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: PEREZ, MARTHA

FACILITY NUMBER: 444415565

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)(3)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
1
2
3
4
Licensee will provide receipt of purchase and documentation to LPA
Type B
Section Cited
CCR
102425(a)(5)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (5) Fitted sheets shall be replaced when wet or soiled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
1
2
3
4
Licensee will provide receipt of purchase and documentation to LPA
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:Susy Cervantes
LICENSING EVALUATOR NAME:Darnella Barnes
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6