Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414668
Report Date: 06/07/2018
Date Signed: 06/07/2018 04:20:37 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:HERNANDEZ, MARIA DEL PILARFACILITY NUMBER:
434414668
ADMINISTRATOR:HERNANDEZ, MARIA DEL PILARFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 704-6266
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:14CENSUS: 14DATE:
06/07/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Maria Del Pilar HernandezTIME COMPLETED:
04:30 PM
NARRATIVE
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LPA Deanna Villagrana met with licensee's assistant Antonio Luna for an unannounced annual/random inspection. LPA explained the nature of today’s inspection to her. Antonio stated licensee Maria was not home. Present were licensee's assistant Antonio and a lady named Gabriela Salazar who stopped by with licensee's grand daughter's ages 5 and 4 with her own daughter who is 4 months. LPA also observed 6 children sleeping in a bedroom and 4 children playing outside in the backyard. Gabriela left the home before Maria arrived. Maria and her husband arrived 15 minutes after LPA arrived. Maria was out of ratio. Maria stated one child is not part of her day care and was on a play date with her grandchildren but the child remained in the home after Gabriela left with Maria's grandchildren. Days and hours of operation are Monday to Friday, 8:00am to 6:00pm. The adults that reside in the home are licensee and her husband.

A review of staff records on 06/05/2018 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, with heating and ventilation for safety and comfort of the children. LPA observed one wall heater barricaded in the home. LPA observed another wall heater in the hallway without a barricade. LPA observed a barricaded fireplace. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed cleaning compounds such as dish detergent and Clorox Wipes under the kitchen sink, medications and shampoos in the bathroom used by children, knives in a kitchen drawer, diaper rash medicine in a drawer in the day care area accessible to children. LPA observed a fully charged 2A10BC fire extinguisher. LPA observed a working combination smoke and carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: two bedrooms and laundry room area.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2018
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 4
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: HERNANDEZ, MARIA DEL PILAR
FACILITY NUMBER: 434414668
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2018
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 understands these items must be inaccessible to children and removed items immediately. Deficiency cleared today.
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LPA observed cleaning compounds such as dish detergent and Clorox Wipes under the kitchen sink, medications and shampoos in the bathroom used by children, knives in a kitchen drawer, diaper rash medicine in a drawer in the day care area accessible to children.
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Type A
06/08/2018
Section Cited
CCR
102416.5(a)
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102416.5(a) Staffing Ratio and Capacity. The capacity specified on the license shall be the maximum number of children for whom care can be provided.
LPA also observed 6 children sleeping in a bedroom and 4 children playing outside in the backyard. Gabriela left the home
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Licensee understands day care reverts to a small license when only her or her assistant is available. Licensee is to cease operating out of ratio and send a plan of correction on how she will make sure day care is incompliance.
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before Maria arrived. Maria arrived 15 minutes after LPA arrived. Maria was out of ratio. Maria stated one child is not part of her day care and was on a play date with her grandchildren but the child remained in the home after Gabriela left with Maria's grandchildren.
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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: 06/07/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2018
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: HERNANDEZ, MARIA DEL PILAR
FACILITY NUMBER: 434414668
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2018
Section Cited
CCR
102417(g)(1)
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102417(g)(1) Operation of a Family Child Care Home. Fire Places and open space heaters shall be screened to prevent access by children.

LPA observed another wall heater in the hallway without a barricade.
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Licensee is to barricade the wall heater in the hallway and send in pictures of barricaded wall heater to CCLD by POC date.
Type B
07/05/2018
Section Cited
CCR
102418(g)
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102418(g) Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.

Child 2's immunization records must be updated.
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Licensee will submit updated immunization's for child 2 to CCLD by POC date.
Type B
07/05/2018
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 and December 1 of each year.
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Licensee will submit updated vaccinations for herself, her husband and her assistant to CCLD by POC date.
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LPA discussed SB792 Immunization Requirements and observed licensee her husband and her assistant do not have current immunization's against influenza, pertussis and measles on file.
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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: 06/07/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2018
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: HERNANDEZ, MARIA DEL PILAR
FACILITY NUMBER: 434414668
VISIT DATE: 06/07/2018
NARRATIVE
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There are no bodies of water. Backyard is fenced. Off limits outdoor: back yard storage which Maria states she plans to use in the future for the children. LPA observed two bunnies, 7 birds and licensee states she has two dogs in the home.

LPA observed licensee and her assistant have current CPR and First Aid certification. Licensee’s expires 08/2019 and assistant's 05/2019. LPA observed a current roster of the children and a fire and disaster drill log which was last completed in 01/22/2018. LPA reviewed nine children's files and observed all forms are completed. Child 2's immunization records must be updated. LPA observed licensee is insured with Travelers Insurance and it expires on 04/13/2019. LPA discussed SB792 Immunization Requirements and observed licensee her husband and her assistant do not have current immunization's against influenza, pertussis and measles 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: 06/07/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2018
LIC809 (FAS) - (06/04)
Page: 4 of 4