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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274413163
Report Date: 07/11/2023
Date Signed: 07/11/2023 04:23:09 PM

Document Has Been Signed on 07/11/2023 04:23 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:BECERRA, DIANAFACILITY NUMBER:
274413163
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Diana BecerraTIME COMPLETED:
04:45 PM
NARRATIVE
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On 07/11/2023 at 12:30 PM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee Diana Becerra, for an annual inspection. Present with licensee were 17 year old daughter who is helping and licensee spouse, with 6 children: (3) preschool age, 3 school age, two children in care are licensee children. Adults living in the home are licensee with her spouse Octavio. Three minor children live in the home. Days and hours of operation are Monday through Friday 06:00 AM to 05:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 07/10/2023 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA inspected inside and outside of two-story home. License owns the home and Licensee states she does have liability insurance for a family childcare home (FCCH) with DCI. LPA observed a barricaded fireplace, no wall heater, no barricaded stairs, and no bodies of water. Licensee stated there are no weapons. Licensee states she has a vaccinated cat. LPA observed a 3A40BC fire extinguisher last serviced on 01/31/2023. Carbon Monoxide and smoke detectors are operable. Sharp objects, medicines, poisons, and cleaning supplies were accessible to children in care. On limit bathroom had a bottle of shampoo and off limit upstairs laundry room had a five gallon laundry detergent accessible to children in care. Off limit areas inside the home: entire upstairs area, living room, formal dining room and attached garage. On limit areas: Kitchen, bottom bedroom, first floor loft, full bathroom, half bathroom by hallway and living room #2. Backyard is fenced. Off limits outdoor: left yard area. On limit areas outside the home: rear yard play area with gazebo and right side yard area.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 8 children according to her license. Licensee stated she does transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.

Continues report dated 07/11/2023 pg. 1/3

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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 5
Document Has Been Signed on 07/11/2023 04:23 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 07/11/2023 at 02:48 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: BECERRA, DIANA
FACILITY NUMBER: 274413163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(3)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Stairs were not barricaded during site visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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Licensee will send a written statement on how stairs will be secured and barricaded and will also submit proof of barricaded stairs to the San Jose Regional Office by close of business on 7/12/2023.
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in off limit laundry room had a 5 gallon can of laundry detergent, On limit bathroom tub had bottle of shampoo which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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Licensee will submit photos of bottom bathroom tub and photos of barricaded stairs leading to second floor and a written statement of her plan to keep deficiency from happening again by close of business on 07/12/2023
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 Segura
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/11/2023 04:23 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 07/11/2023 at 02:48 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: BECERRA, DIANA
FACILITY NUMBER: 274413163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in last disaster drill conducted on 09/19/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Licensee will submit a copy of completed disaster drill to the San Jose Regional Office by close of business 07/26/2023.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in LIC 627 Consent For Medical Treatment missing for Child 1 (C1), c2, c3, c4 and c5, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Licensee will submit copies of signed LIC 627 to the San Jose Regional Office by close of business 07/26/23.
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 Segura
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


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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: BECERRA, DIANA
FACILITY NUMBER: 274413163
VISIT DATE: 07/11/2023
NARRATIVE
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Continuation of report dated 07/11/2023 pg. 2/3

LPA observed a current roster of the children. LPA observed a fire and disaster drill log last performed on 09/19/2022. LPA reviewed 5 children’s files and observed not all required documentation was complying, LIC627 Consent for Emergency Medical Treatment is missing for Child 1(c1), c2, c3, c4 and c5. Infant individual sleeping plan (LIC 9227) for each infant under 12 months and a 15-minute check sleep log for infants under 24 months was discussed. Licensee CPR/1st Aid expiring on 01/16/25. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is current for licensee, and all adults residing in the home.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS currently. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Continues report dated 07/11/2023 pg. 2/3

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
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: BECERRA, DIANA
FACILITY NUMBER: 274413163
VISIT DATE: 07/11/2023
NARRATIVE
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Continuation of report dated 07/11/2023 pg. 3/3

Type A deficiencies were cited during today's visit. LPA Teodoro Trujillo informed licensee Diana Becerra that this report dated 07/11/2023 document(s) 2 (two) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA Teodoro Trujillo informed the licensee Diana Becerra to provide a copy of this licensing report dated 07/11/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.
Exit interview conducted and report was reviewed with the licensee, Diana Becerra. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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