Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415784
Report Date: 02/28/2019
Date Signed: 02/28/2019 04:18:02 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:HEREDIA ANTON, MARIA & INFANTE LOPEZ, KARLAFACILITY NUMBER:
434415784
ADMINISTRATOR:HEREDIA ANTON, MARIA & INFFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 630-9036
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:14CENSUS: 12DATE:
02/28/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Karla Infante Lopez TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Zaid Hakim conducted an Unannounced Annual / Random Inspection at the facility today. Upon arrival, LPA observed three (3) infants, eight (8) preschool age children, and at least two (2) staff engaging in daily activities and met with Ms. Karla Infante Lopez, Licensee. The Licensees are the only individuals that reside in the home and all adults maintain valid background clearance. The days and hours of operation are Monday through Friday 8:00am to 5:00pm and is licensed for a maximum capacity of 14 children. LPA observed required postings near the facility entrance; including but not limited to the License to operate, the Emergency Disaster Plan (LIC 610) and Notification of Parents Rights (PUB 393).

LPA toured the facility inside and out and observed all indoor and outdoor activity areas. LPA observed door locks securing off limit areas which include the kitchen and one bedroom. The facility is equipped with at least one functioning smoke detector, at least one carbon monoxide detector, one complete first aid kit and at least one 2A10BC fire extinguisher. The Licensee stated that fire safety items and fire extinguishers are maintained at least once every 12 months. Toxic cleaning supplies and other items that pose a danger to children are securely stored in inaccessible locations. The home has sufficient and safe toys, equipment, and supplies. The home was observed to be safe and orderly. The outdoor play area was observed to be free from hazards and equipped with age appropriate toys and equipment. The Licensee stated that there are no weapons or firearms in the home, no fireplaces in the home, and no bodies of water of the premises. The kitchen and food preparation / service areas were observed to be clean and fully furnished with supplies. The Licensee provides meals and snacks to children, parents are informed of what is served daily, and she is aware of any food allergies or dietary restrictions. The Licensee stated that there are no bouncers in the home and understands that bouncers may not be used in family home day cares. LPA observed all furnishings used by children to be safe and in good condition. LPA and the Licensee discussed safe sleep for infants in care, children's personal rights and age appropriate equipment.

CONTINUATION ON FOLLOWING PAGE (PAGE #2 - REPORT DATED 02/28/2019:
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Zaid HakimTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2019
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: HEREDIA ANTON, MARIA & INFANTE LOPEZ, KARLA
FACILITY NUMBER: 434415784
VISIT DATE: 02/28/2019
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CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 02/28/2019):

LPA advised the Licensee of the new immunization requirement (pertussis, measles, and flu vaccines) for all staff that work directly with the children and the required "Mandated Reporter" training that all staff will be required to complete starting January 1, 2018. LPA referred the Licensee to the Department website to access the training: https://mandatedreporterca.com/

LPA advised that licensing forms and all other information can be found at:
http://www.cdss.ca.gov/inforesources/Child-Care-Licensing.

LPA and the Licensee discussed changes to the License such as one of the Licensee's potentially moving out of the home or retiring. LPA advised the following may be required:
- Updated LIC 279 (Application) and all other LIC forms requiring updates
- A new license number and the Pre-Licensing process with submission of a new application

A Notice of Site Visit has been issued and must remain posted for 30 consecutive days.

No deficiencies have been cited as a result of today's inspection. Exit interview conducted with Ms. Karla Infante Lopez, Licensee.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Zaid HakimTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2019
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: HEREDIA ANTON, MARIA & INFANTE LOPEZ, KARLA
FACILITY NUMBER: 434415784
VISIT DATE: 02/28/2019
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 02/15/2019):

The Licensee maintains a roster of enrolled children. LPA reviewed a random sample of child records and each record was observed to be complete and up to date. Emergency disaster drills are documented and conducted as required, last of which being done in 01/2019. LPA confirmed that at least one staff maintains valid pediatric CPR and first aid with an expiration month of 08/2020 and 02/2021. LPA and the Licensee discussed emergency disaster procedures in the event of a natural or man-made disaster. LPA observed the outdoor play area in the front yard to be safe for children and free from hazards. LPA observed that there is secure perimeter fencing enclosing the area and the Licensee understands close supervision should be provided outside as this area borders a public street. The Licensee does not provide transportation to day care children and understands in the event of transportation being provided, that children may not be left in vehicles unattended and seat belt laws must be abided by at all times. The Licensee does not assist any children with Medications at this time.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

A review of staff records during today's inspection indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded The licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

CONTINUATION ON FOLLOWING PAGE (PAGE #3 - REPORT DATED 02/28/2019):
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Zaid HakimTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2019
LIC809 (FAS) - (06/04)
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