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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412550
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:18:17 PM

Document Has Been Signed on 01/24/2024 03:18 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:HEDMAN, ANNEFACILITY NUMBER:
434412550
ADMINISTRATOR:ANNE HEDMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 838-9682
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
01/24/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Anne HedmanTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Samantha Yip and Mandeep Kaur conducted an unannounced Required- 3 Year inspection. LPAs met with Licensee Anne Hedman and explained the reason for the inspection. Present during today's inspection were Licensee, her mother, two assistants, and 10 children, whom three (3) were infant age.

There is a board to post required postings, such as license and notification of parent's rights. The hours of operation are Monday through Friday 6:30AM to 6PM.

LPAs toured the inside and outside of the home with Licensee. The off-limit areas of the home are the kitchen, two bedroom to the left of the front door, and detached garage. There is a fireplace in the home that is barricaded. Disinfectant, cleaning supplies, and other items that could be dangerous were inaccessible. LPA observed that there is a cabinet with a latch in the master bedroom that has medication inside. LPA discussed with Licensee about putting a magnet lock. There are toys and equipment for the children. LPA observed that there was a baby bouncer in the master bedroom on top of the bed. There were no children using it at the time. Licensee removed it during today's inspection. There is a functioning smoke and carbon monoxide detector. Licensee has a size 1 fire extinguisher. LPA discussed with Licensee that the fire extinguisher needs to be at least a size 2 or larger. Licensee stated that there are no weapons, such as firearms, stored in the home. The last fire/disaster drill was conducted on 11/16/2023.

The backyard is used and is fenced. The off-limit areas outside are the right side and two sheds. There are equipment for children. There were no bodies of water observed during today's inspection.
--------------------CONTINUES ON 809 DATED 01/24/2024 PAGE 2------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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: HEDMAN, ANNE
FACILITY NUMBER: 434412550
VISIT DATE: 01/24/2024
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----------------CONTINUATION OF 809 DATED 01/24/2024 PAGE 1------------

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. LPA discussed that she check infants every 15 minutes and document it. LPA also discussed about the door needs to be open.

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)/ (800) 514-0383 (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 does not transport children, but understands that children cannot be left alone and unattended in parked vehicles.

Meals are brought from home. Lunch boxes are labeled with the child's name, but the containers are not labeled.

A copy of the facility roster was obtained. 10 children's files were reviewed during today's inspection. The records reviewed include but not limited to parent's rights and immunization records.

Licensee and three assistant files were reviewed. The records reviewed include but not limited to Mandated Reporter training and immunization records for measles, pertussis, and influenza. Licensee and two other assistants have a valid CPR/1st Aid. Licensee's CPR/1st Aid expires on 09/2025.

---------------CONTINUES ON 809 DATED 01/24/2024 PAGE 3-----------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
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: HEDMAN, ANNE
FACILITY NUMBER: 434412550
VISIT DATE: 01/24/2024
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----------------CONTINUATION OF 809 DATED 01/24/2024 PAGE 2------------

The adults living in the home are Licensee and her mother. All adults have cleared criminal record clearance and child abuse index. 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 Child Care 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.

During the exit interview, the Licensee, Anne Hedman, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Licensee will submit the following:
- proof of a size 2 or larger fire extinguisher by 02/02/2024
- A-1's TB test
- A-2's TB, immunization records for measles and pertussis
- updated LIC 279

As a result of this inspection, Type B citations were issued. Exit interview conducted and report was reviewed with Licensee Anne Hedman. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2024 03:18 PM - It Cannot Be Edited


Created By: Samantha Yip On 01/24/2024 at 01:21 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: HEDMAN, ANNE
FACILITY NUMBER: 434412550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. Licensee did not document the date, child's name, and time checked for infants who are napping.
POC Due Date: 02/02/2024
Plan of Correction
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By 02/02/2024, Licensee stated that she will check napping infants every 15 minutes and document the date, name of child, and time checked. Licensee will submit log to Licensing.
Type B
Section Cited
CCR
102369(b)(9)
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

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. A-1 and A-2 did not have TB clearance.
POC Due Date: 03/01/2024
Plan of Correction
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By POC 03/01/2024, A-1 and A-2 will complete TB test and send proof to Licensing.
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


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