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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274416226
Report Date: 06/29/2021
Date Signed: 06/30/2021 04:27:41 PM

Document Has Been Signed on 06/30/2021 04:27 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:DIAZ, AMYFACILITY NUMBER:
274416226
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 AM
MET WITH:Amy DiazTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Larios met with Amy Diaz, Licensee, for an unannounced Required – 1 year annual inspection. LPA were granted access to the home by the Licensee. LPA also observed four children (2 preschool & 2 school age). The Licensee was operating within her capacity and ratio requirements during today's inspection. LPA observed the required postings, including the facility license, near the front entrance to the home. The home has a working telephone (831) 272-3150. Days and hours of operation are Monday - Friday from 6:30AM to 6:00PM and Saturday's 6:30AM-1:00PM. The Licensee and her fiance, Juan Munguia, and adult daughters Sunshine Diaz & Felicia Diaz are the only adults who reside in the home. Licensee has certification for CPR and First Aid that is current and expires August 10, 2021

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 06/22/2021. The Licensee, has required vaccinations (MMR, Tdap, & flu). The Licensee has current Mandated Reporter Training for Child Care Workers on file (exp: 09/30/2019). LPA reviewed four children's files and observed current and updated Identification and Emergency Information (LIC 700) and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. The Licensee states that a child will be isolated in the front entry way of kitchen if needed to because of illness or communicable disease.

Safe sleep updated: LPA discussed the new “Safe Sleep” regulations with the Licensee and provided a copy of the regulations, including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee.

REPORT CONTINUED ON FOLLOWING PAGE #2 - REPORT DATED 06/29/2021
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
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: DIAZ, AMY
FACILITY NUMBER: 274416226
VISIT DATE: 06/29/2021
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 06/29/2021)
Supervision of children was discussed with the 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. The Licensee understands her capacity options and she understands that she cannot have more than 8 children in the home at any time. Licensee stated does not transport children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

LPA discussed the requirements of AB 633 with the Licensee and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and the Licensee understands the requirements. LPA also discussed "zero tolerance" related regulations with the Licensee and advised her of the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA conducted an exit interview with the Licensee and deficiency was issued during today's inspection.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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: DIAZ, AMY
FACILITY NUMBER: 274416226
VISIT DATE: 06/29/2021
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 06/29/2021)
LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.

LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. There are no stairs inside the home. There is a fireplace inside the home that is screened. Off limit areas inside the home: three bedrooms, and car garage. Off limit areas outside the home are left side locked dog zone.

LPA observed a fully charged 2A10BC fire extinguisher, working carbon monoxide smoke detector was not operational, no bodies of water, and fenced backyard. The Licensee states that she does not have any weapons in the home. The facility has two dog. Licensee stated the dog is vaccinated and kept away during day-care hours. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Any poisons are in upper cabinets, garage, and bedrooms off limits and inaccessible to the day care children.

A review of staff records on June 29, 2021 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.

REPORT CONTINUED ON FOLLOWING PAGE #3 - REPORT DATED 06/29/2021
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2021 04:27 PM - It Cannot Be Edited


Created By: Elizabeth Larios On 06/29/2021 at 02:17 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: DIAZ, AMY
FACILITY NUMBER: 274416226

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2021
Section Cited
CCR
102417(g)(1)

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Operation of a Family Child Home: Fireplaces and open-face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal.
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Licensee replaced battery of smoke detector. Deficiency is cleared during today's inspection.
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This requirement was not met as evidenced by LPA testing and observing Licensee not having a operational smoke detector. This poses a potential risk to the Health, Safety or Personal Rights to children in care.
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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:Anthony Studebaker
LICENSING EVALUATOR NAME:Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021


LIC809 (FAS) - (06/04)
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