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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415983
Report Date: 05/10/2023
Date Signed: 05/10/2023 01:25:54 PM

Document Has Been Signed on 05/10/2023 01:25 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:CONTRERAS, ADELAFACILITY NUMBER:
274415983
ADMINISTRATOR:ADELA CONTRERASFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(941) 580-7943
CITY:GREENFIELDSTATE: CAZIP CODE:
93927
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Adela ContrerasTIME COMPLETED:
01:35 PM
NARRATIVE
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On 05/10/2023 at 10:50 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Adela Contreras, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee and assistant Cindy Hernandez, with 6 children: two infants and four preschool. Adults living in the home are licensee, their spouse and two with two children ages 15 and 12. Days and hours of operation are Monday through Friday 6:00 AM to 6:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 04/17/2023 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 observed an adult, Servando Alvarez Ramirez, has fingerprints pending, licensee informed LPA that it's their brother in law and they do not live or work at the facility.

LPA inspected inside and outside of the home. LPA observed a covered fireplace, no wall heater, no stairs, and a fish tank that has a cover. Licensee stated there are no weapons. Licensee stated they have dogs and they are vaccinated. LPA observed a 3A40BC fire extinguisher that was fully charged. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored under the locked sink and a top kitchen cabinet. Backyard is fenced. Off limit areas: four bedrooms, one bathroom, garage, left and right side yards.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 8 children according to their license. Licensee stated they do not 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 on report dated 05/10/2023 pg. 1/2
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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 4
Document Has Been Signed on 05/10/2023 01:25 PM - It Cannot Be Edited


Created By: Susy Cervantes On 05/10/2023 at 12:30 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: CONTRERAS, ADELA
FACILITY NUMBER: 274415983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which Child 05 and 06 are missing LIC 995A which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee will provide LIC 995A to parents of child 05 and 06 to be completed and will submit a copy of the form to the San Jose Regional Office by close of business on May 24, 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:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/10/2023 01:25 PM - It Cannot Be Edited


Created By: Susy Cervantes On 05/10/2023 at 12:30 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: CONTRERAS, ADELA
FACILITY NUMBER: 274415983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which Child 03 and 06 are missing their 15 minute sleep log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee will create a sleep log and will check sleeping infants every 15 minutes and will document Child 03 and 06's sleep. Licensee will submit a copy of the sleep log with 2 to 3 days worth of documentation and will submit the log to the San Jose Regional Office by close of business on May 24, 2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
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:Mary Segura
LICENSING EVALUATOR NAME:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


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: CONTRERAS, ADELA
FACILITY NUMBER: 274415983
VISIT DATE: 05/10/2023
NARRATIVE
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Continuation of report dated 05/10/2023 pg. 2/2

LPA took a picture of a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 03/02/23. LPA reviewed 6 children’s files and observed Child 03 and 06 are missing their 15 minute sleep log. LPA observed that the Licensee and assistant have Mandated Reporter training that was completed on 04/22/22 and 03/15/23. Licensee and assistant have Pediatric CPR/1st Aid expiring 12/05/24 and 03/21/25. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee and assistant.

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 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.

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.

Type B deficiencies were cited during today's visit. 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 in Spanish with the licensee, Adela Contreras. 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: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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