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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415893
Report Date: 09/09/2022
Date Signed: 09/14/2022 03:27:40 PM

Document Has Been Signed on 09/14/2022 03:27 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:PEREZ, MA DE LA LUZFACILITY NUMBER:
444415893
ADMINISTRATOR:PEREZ, MA DE LA LUZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 536-5050
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Ma De La Luz PerezTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee, Ma De La Luz Perez for an unannounced 1 year required inspection. LPA was granted access to the home by the Licensee. LPA observed 6 preschool age children and Licensee's adult son (Octavio Omar Perez) in the home during today's inspection. Licensee was operating within the capacity and ratio requirements. LPA observed the required postings, including the facility license, near the main day care area of the home. Days and hours of operation are Monday - Friday from 6:00 AM to 6:00 PM. Adults residing in the home are Licensee, Licensee's daughter (Carla Perez) and adult son (Octavio Omar Perez).

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on July 9, 2022. Licensee states that she does have liability insurance for the day care. LPA reviewed current policy. Licensee has current CPR and First Aid certifications (expiration: 08/06/2024). Licensee has the required vaccines (MMR, Tdap and flu). Licensee is current with the Mandated Reporter Training for Child Care Workers (expiration: 04/25/2023). LPA reviewed six children's files; files are missing parents rights form. LPA notes that Licensee is using emergency card from the Pajaro Valley Unified School District (Migrant head start). LPA reviewed two staff files (Licensee & Licensee's daughter) and the files were complete with the required forms and immunization records.

LPA inspected the indoor and outdoor areas of the home during today's inspection. Off limit areas inside the home are: Three bedrooms, one bathroom, and the attached garage. Off limits areas outside: The right and left side yards. Licensee uses the middle of the backyard for day care children; The area is fenced. Licensee has a working telephone in the home and provided her cell phone number (831) 251-7939. The home is clean, orderly, (including heating/air conditioning/ventilation), and safe for the day care children. There are safe & age appropriate toys, play equipment, and materials for the children in the home.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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: PEREZ, MA DE LA LUZ
FACILITY NUMBER: 444415893
VISIT DATE: 09/09/2022
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LPA observed a fully charged 3A40BC fire extinguisher (last serviced on 08/09/22). The smoke and carbon monoxide detector was tested and proved to be functioninh. Licensee states that she does not have any weapons. Licensee has a pet cat that is kept in off limit bedroom. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Licensee understands that all poisons are locked and inaccessible to the day care children.
Licensee provides all food and snacks to children. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored. Licensee has a first aid kit in the home which includes a touch less thermometer. Licensee understands that smoking is prohibited in the home.

Licensee states that she does not administer any medications to the day care children at this time. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

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 the capacity/ratio options and she understands that she cannot have more than 14 children present in the home without at least two qualified adults present. Licensee states that a child will be isolated in the living room area if necessary due to illness or communicable disease. Licensee states that she 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.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
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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: PEREZ, MA DE LA LUZ
FACILITY NUMBER: 444415893
VISIT DATE: 09/09/2022
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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, Ma De La Luz Perez. Deficiencies issued during today's inspection.

LPA requests that Licensee submit an updated LIC 279 form.

LIC 508 for her son, Octavio Perez and his TB test.

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: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/14/2022 03:27 PM - It Cannot Be Edited


Created By: Elizabeth Berumen On 09/09/2022 at 01:07 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, MA DE LA LUZ
FACILITY NUMBER: 444415893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Children files are missing the Notification of Parents Rights (LIC995A) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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LPA Berumen provided Licensee, Ma De La Luz Perez a copy of the LIC 995A to make copies and provide to parents. Parents are to keep top portion of form, sign the bottom and Licensee agrees to file the bottom portion of LIC995A in each child's file.

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: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


LIC809 (FAS) - (06/04)
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