Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413653
Report Date: 07/14/2016
Date Signed: 07/14/2016 09:23:43 AM

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:TERRAZAS, AMORFACILITY NUMBER:
434413653
ADMINISTRATOR:TERRAZAS, AMORFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 468-1788
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:14CENSUS: 9DATE:
07/14/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:AmorTIME COMPLETED:
09:37 AM
NARRATIVE
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An unannounced Annual/ Random visit was made to the facility. Upon arrival observed licensee's three children getting ready to leave for summer camp. Her first child and her helper arrived at 8:20 AM.
Licensee understands that all adults that live in the home or help with the children must have a clearance before they can be present. All adults have all required finger prints clearances.
Hours of operation is Monday through Friday from 8 AM to 4:30 PM.
She is renting her house and resides in the house with her 3 children ages 5,9,11 y.o. & her husband.
Off limit areas: Master suite, kid's bedroom and one side yard.
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. Amor states there are no weapons in the home.
Cleaning supplies, medicines & similar items stored inaccessible to children.
There is a fully charged and correct size fire extinguisher. There is working smoke alarm and Carbon Monoxide detector.
Home is clean. They have a wall heater and portable air condition.
Licensee has working land line/ telephone
Children were supervised during the visit.
Discussed children supervision with Amor. Ratio and supervision were correct during today's visit.
Children play in the backyard which is fenced. There are plenty of age appropriate toys and play equipment
Amor has a current children roster.
Fire/disaster drills are documented. Last drill was conducted on 05/23/2016.

See next page for continuation of the report:
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2016
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 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: TERRAZAS, AMOR
FACILITY NUMBER: 434413653
VISIT DATE: 07/14/2016
NARRATIVE
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Amor has an expire CPR training. Advised Amor that she needs to obtain one hour in children's nutrition.
Licensee doesn't transport children.
Children's file were review.
The following type B deficiency is 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: 07/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2016
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: TERRAZAS, AMOR
FACILITY NUMBER: 434413653
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2016
Section Cited
102416(c)
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102416(c) Personnel Requirements. 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.
Amor has an expired CPR training.
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Amor needs to mail analyst updated CPR 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: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2016
LIC809 (FAS) - (06/04)
Page: 3 of 3