Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413319
Report Date: 07/05/2016
Date Signed: 07/05/2016 01:18:45 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:PEREZ PALMA, KATIAFACILITY NUMBER:
434413319
ADMINISTRATOR:PEREZ PALMA, KATIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 283-3805
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:14CENSUS: 10DATE:
07/05/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Evelyn ( Xiomara)TIME COMPLETED:
01:20 PM
NARRATIVE
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An unannounced annual random visit was made to the facility. upon arrival Evelyn stated that Katia is not home and had a dentist appointment. She called her and after 30 minutes Katia arrived. She assured me that she resides in the house. Analyst stated that during last visit she was not home either.
She is renting the house and resides in the house with her 2 y.o. Today, her son was not home.
Toured facility and Off limit areas are; Katia's bedroom, her son's bedroom, garage and dog run.
Analyst requested an up dated Lic 200 that includes her son's name.
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
There are no bodies of water in the backyard. Katia stated that there are no weapons in the home.
Cleaning supplies, medicines & similar items stored inaccessible to children
There is no Fireplace in the house.
There is a fully charged and correct size fire extinguisher. There is a working smoke alarm and carbon monoxide. Home is clean. Today, the house was warm and Katia stated that she has an air condition that she could turn on.
Analyst advised her that during summer she needs to turn on the air before children arrival.
Licensee has working land line/ telephone.
Children were supervised during the visit.
Discussed children supervision with Katia. Ratio and supervision were correct during today's visit.
Children play in the backyard which is fenced.
Katia has a current children roster.
Fire/disaster drills are documented. Last drill was conducted in March 2016.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2016
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 PALMA, KATIA
FACILITY NUMBER: 434413319
VISIT DATE: 07/05/2016
NARRATIVE
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Katia has a current pediatric 1st aid/CPR which expires on 1/19/2018. Advised Katia that she needs to obtain one hour in children's nutrition.
Licensee doesn't transport children.
Children's file were review. Some of the children did not have their immunization.
The following type B deficiencies are cited;
Notice of site visit was posted.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2016
LIC809 (FAS) - (06/04)
Page: 2 of 3


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 PALMA, KATIA
FACILITY NUMBER: 434413319
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2016
Section Cited
102418
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102418 Immunization
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
Couple of the children did not have their immunization records.
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She needs to update all immunization records.
Type B
07/15/2016
Section Cited
102423(a)(2)
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102423(a)(2) Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations, furnishing and equipment.
Children's hand were not washed prior to serving their meal. Upon arrival observed children playing in the yard. They served meal in the yard .
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Children's hand must be washed prior to serving meal. Requested a written plan of correction.
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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: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2016
LIC809 (FAS) - (06/04)
Page: 3 of 3