Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411683
Report Date: 07/19/2018
Date Signed: 07/19/2018 05:03:08 PM

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:BARRENECHEA, JOHANAFACILITY NUMBER:
434411683
ADMINISTRATOR:BARRENECHEA, JOHANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 806-4794
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:14CENSUS: 11DATE:
07/19/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Evelyn GironTIME COMPLETED:
05:10 PM
NARRATIVE
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LPA Deanna Villagrana met with licensee's assistant Evelyn Giron for an unannounced annual/random inspection. LPA explained the nature of today’s inspection to her. Present were licensee two assistant's Evelyn Giron and Gladis Eguizaballinare with 11 day care children including 3 infants. Evelyn states licensee was at the doctor's office with her daughter. Days and hours of operation are Monday to Friday, 7:30am to 5:30pm. The adults that reside in the home are licensee and her 6-year-old daughter. Licensee arrived a short time later with her daughter and nephew. Licensee stated she was going to take them to soccer practice.

A review of staff records on 07/17/2018 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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 prevents them from returning to the home or having contact with children in care.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly. LPA observed the children sleeping in the garage area in very warm conditions without proper ventilation for safety and comfort of the children. LPA observed a fireplace that is barricaded by a metal gate and had a candle holder inside of fireplace. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed a knife and matches in a kitchen drawer, toothpaste on the bathroom counter that children use, Clorox wipes on a shelf in the back yard and charcoal and lighter fluid in an unlocked storage outside accessible to children. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed a working smoke detector. LPA did not observe a working carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: two bedrooms. There are no bodies of water. Backyard is fenced. Off limits outdoor: right side of home that is fenced off to children. LPA observed one pet dog in the home. Licensee states dog stays is vaccinated.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2018
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: BARRENECHEA, JOHANA
FACILITY NUMBER: 434411683
VISIT DATE: 07/19/2018
NARRATIVE
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LPA observed licensee and her assistants have current CPR and First Aid certification that expire 01/10/2020. Licensee and her assistant's have not completed Mandated Reporter training. Licensee's assistant's speak Spanish and will complete when available. LPA did not observe a current roster of the children. LPA observed a fire and disaster drill log which was last completed 02/02/2018. LPA reviewed ten children's files and observed all forms are completed and children have current immunization records. Child 11's entire file is missing. Licensee states day care is not insured. LPA observed LIC282 in each child's file. LPA discussed SB792 Immunization Requirements and observed licensee does not have current immunization's against pertussis and measles. Licensee's assistant's have all required immunization records on file.


Supervision of children was discussed with 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 her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed Zero Tolerance with $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

The following Type A and B deficiencies were cited.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2018
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: BARRENECHEA, JOHANA
FACILITY NUMBER: 434411683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2018
Section Cited
CCR
102421(b)
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102421(b) Childs Records. The licensee shall maintain, in each child’s record, a copy of the emergency information card required in Section 102417(g) (7).

Child 11's entire file is missing.
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Licensee will submit copy of child 11's file to CCLD by POC date.
Type B
08/02/2018
Section Cited
HSC
1596.822(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 provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete
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Licensee will submit a copy of completion of Mandated Reporter training for herself to CCLD by POC date. Licensee will ensure assistant's will complete when Spanish version is available.
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renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
Licensee has not completed Mandated Reporter training.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2018
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: BARRENECHEA, JOHANA
FACILITY NUMBER: 434411683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2018
Section Cited
CCR
102417(b)
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102417(b) Operation of a Family Child Care Home. The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.
LPA observed the children sleeping in the garage area in very warm conditions without proper ventilation for safety and comfort of the children.
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Licensee will submit a plan on how she plans to keep room at a comfortable temperature for children to CCLD by POC date. May include photos of purchase items.
Type B
07/19/2018
Section Cited
CCR
102417(g)(8)
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102417(g)(8) Operation of a Family Child Care Home. All homes shall have a current roster of the children.

LPA did not observe a current roster of the children.
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Licensee completed roster during visit. Deficiency cleared today.
Type B
08/02/2018
Section Cited
HSC
1597.622(a)(1)
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1597.622 (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1
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Licensee will submit current immunization's for herself to CCLD by POC date.
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and December 1 of each year.

LPA discussed SB792 Immunization Requirements and observed licensee does not have current immunization's against pertussis and measles.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2018
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: BARRENECHEA, JOHANA
FACILITY NUMBER: 434411683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2018
Section Cited
CCR
102417(g)(4)
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102417(g)(4) Operation of a Family Child Care Home. Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger to children shall be stored where they are inaccessible to children.
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Licensee's assistant Evelyn removed items immediately during visit. Deficiency cleared today.
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LPA observed a knife and matches in a kitchen drawer, toothpaste on the bathroom counter that children use, Clorox wipes on a shelf in the back yard and charcoal and lighter fluid in an unlocked storage outside accessible to children.
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Type A
07/20/2018
Section Cited
HSC
1596.954
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CARBON MONOXIDE DETECTORS REQUIRED. Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account
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Licensee will submit proof of installed Carbon Monoxide detector and proof of purchase to CCLD by POC date.
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for the presence of these detectors during inspections.

LPA did not observe a working carbon monoxide detector.
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AB633 Parent Notification is required.

This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements
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 SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2018
LIC809 (FAS) - (06/04)
Page: 3 of 5