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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444416383
Report Date: 04/01/2025
Date Signed: 04/09/2025 04:31:09 PM

Document Has Been Signed on 04/09/2025 04:31 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:MARTINEZ, JESSICAFACILITY NUMBER:
444416383
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 331-9289
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
04/01/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Jessica MartinezTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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On April 1, 2025, Licensing Program Analysts (LPA) Darnella Barnes conducted an unannounced annual 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 3/5/25, The licensee was reminded of the six-month drill and documentation requirement.

Licensee, Assistant, 3 infants and 5 preschoolers were present, meeting capacity and ratio requirements. Licensee was provided information and reminded of capacity and 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.

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MARTINEZ, JESSICA
FACILITY NUMBER: 444416383
VISIT DATE: 04/01/2025
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The licensee was reminded that children showing signs of illness should be separated from others until it is determined whether they are contagious. They must remain separated until they are no longer infectious or are picked up.

LPA toured the facility, indoor off-limit areas included four bedrooms.. LPA observed the licensee and assistant providing care in a safe and comfortable environment, ensuring children were treated appropriately and free form any form of punishment or mistreatment. The home was clean, well ventilated, and has age-appropriate toys. A fully charged 2A-10B-C fire extinguisher, last serviced 3/5/25, is available, along with working smoke and carbon monoxide detectors, and an operating telephone. In the children’s bathroom under the sink and under the kitchen sink, cleaning compounds and detergents were stored. The locks securing them were not fully secure. The bathroom lock came off with a light tug, while the kitchen lock was loose, and the doors were partially open, allowing them to be easily pulled open and off. All other areas with hazardous items, such as poisons, detergents, cleaning compounds, and medicines are stored out of children’s reach. There is a wood fireplace in the on limits area that is barricaded and per licensee non-usable. Smoking is not permitted, and baby walkers, bouncers, jumpers, and similar items are not allowed.

Outdoor off limit areas include laundry room, garage, storage, shed, driveway, and right side of yard (facing the home) Outdoor play area is fenced and has age-appropriate toys for the children such as;art station, play dough, drama area, library area, toys, blocks puzzles, balls, and play tables. There are boxes in the outdoor children’s play area, stacked at a height that creates a danger to the children due to the potential risk of falling. The licensee was reminded to notify licensing before making any changes to the house or yard.

Licensee CPR/First Aid expired 3/23/25 with mandatory training expiring 5/3/25. The assistant(1) CPR/First Aid expired 3/23/25 with mandatory training expired 3/28/25 . The preventive health certification is on file. LPA reminded the licensee of the two-year renewal requirement.

The facility roster and five children’s files were reviewed, confirming all required forms were complete, Licensee provided review of documentation of proof of liability insurance covering the day care that expires 1/6/26,.

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

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MARTINEZ, JESSICA
FACILITY NUMBER: 444416383
VISIT DATE: 04/01/2025
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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/

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

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MARTINEZ, JESSICA
FACILITY NUMBER: 444416383
VISIT DATE: 04/01/2025
NARRATIVE
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LAST PAGE

The licensee does not transport children, LPA reminded LIcensee that should she elect to transport children that she must have a valid driver's license. 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.

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 3/7/25. A search of the California Attorney General-Megan’s Law website found no registered sex offenders at the facility address.

During today’s inspection, (5) “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: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 04/09/2025 04:31 PM - It Cannot Be Edited


Created By: Darnella Barnes On 04/01/2025 at 01:58 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: MARTINEZ, JESSICA
FACILITY NUMBER: 444416383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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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: 04/15/2025
Plan of Correction
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Licensee will remove all boxes from the outside play area for children and will provide documentation to LPA
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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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: 04/03/2025
Plan of Correction
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Licensee will remove from under childrens bathroom sink and under kitchen sink all hazardous items, such as poisons, detergents, cleaning compounds, and medicines out of children’s reach-to another location laundry room(off limits area) -and provide LPA documentation of completion.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susy Cervantes
NAME OF LICENSING PROGRAM MANAGER:
Darnella Barnes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/09/2025 04:31 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/09/2025 04:09 PM


Created By: Darnella Barnes On 04/01/2025 at 01:58 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MARTINEZ, JESSICA
FACILITY NUMBER: 444416383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rigts risk to persons in care. Licensee's CPR/First Aid is expired.
POC Due Date: 04/22/2025
Plan of Correction
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Licensee will obtain CPR training certification from approved training company and provide LPA with documentation.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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 which poses a potential health, safety or personal rights risk to persons in care. Assistant's Mandated Reporting certificate is expired.
POC Due Date: 04/22/2025
Plan of Correction
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Licensee will have Assistant obtain a current Mandated Reporters training certification from approved training company and provide LPA with documentation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susy Cervantes
NAME OF LICENSING PROGRAM MANAGER:
Darnella Barnes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/09/2025 04:31 PM - It Cannot Be Edited


Created By: Darnella Barnes On 04/01/2025 at 02:02 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: MARTINEZ, JESSICA
FACILITY NUMBER: 444416383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)

(c) The licensee and other personnel as specificied shall complete training on preventative practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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2
3
4
Licensee will have Assistant obtain a current Pediatrict CPR & First Aid training certification from approved training company and provide LPA with documentation
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Susy Cervantes
NAME OF LICENSING PROGRAM MANAGER:
Darnella Barnes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2025


LIC809 (FAS) - (06/04)
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