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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274416226
Report Date: 08/02/2022
Date Signed: 08/03/2022 09:55:50 AM

Document Has Been Signed on 08/03/2022 09:55 AM - 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: 8CENSUS: 8DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Amy Diaz TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Elizabeth Larios met with Amy Diaz, Licensee, for an unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensee. LPA observed nine children in care during inspection. LPA observed the required postings, including the facility license, near the front entrance to the home. Days and hours of operation are Monday - Saturday from 6:30 AM to 6:00 PM. Licensee and spouse & daughter are the only adults residing in the home. Licensee also has a minor child and grandchild residing in the home.

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 June 28, 2022. Licensee does have liability insurance for the day care (expiration 03/23/2022). Licensee has current CPR and First Aid certifications (expiration:10/08/2023). Licensee has the required vaccines (MMR, Tdap, & flu) and is current with the Mandated Reporter Training for Child Care Workers (expiration: 09/29/2023). LPA reviewed six children's files and the files were not complete with the required forms. LPA reviewed one staff file (Licensee) and the file was complete with the required forms.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. The home is clean, orderly, (including heating/fans/ventilation), and safe for the day care children. There are safe & age appropriate toys, play equipment, and materials for the children in the home. There are no stairs inside the home. The off limit areas inside the home are: Master bedroom/bathroom, two bedrooms, all kitchen cabinets, and garage. Off limit areas outside (backyard) is the right side of the house.

LPA observed a fully charged fire extinguisher in kitchen area, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she does not have pets in the home or weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Licensee states that she does not administer any medications to the day care children at this time.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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: 08/02/2022
NARRATIVE
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Licensee states that she provides breakfast, lunch, and snacks to the day care children. Licensee states that she understands that any food brought from home needs to be labeled with each child's name and properly stored. Licensee has a first aid kit in the home. Licensee states that nobody smokes and she understands that smoking is prohibited in the home.

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

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. Licensee understands her capacity/ratio options and she understands that she cannot have more than eight children present in the home. Licensee states that a child will be isolated in hallway or in kitchen area if necessary due to illness or communicable disease. Licensee states that does transport day care children. 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.

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 discussed the safe sleep regulations with the Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the 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.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
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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: 08/02/2022
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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

Exit interview conducted and report was reviewed with the Licensee, Amy Diaz. Deficiencies were issued during today's inspection. A Notice of Site Visit must remain posted for 30 days.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/03/2022 09:55 AM - It Cannot Be Edited


Created By: Elizabeth Larios On 08/02/2022 at 03:13 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: 08/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(10)
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: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in bouncer was in the living room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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Licensee removed bouncer during visit. Deficiency cleared today.
Type B
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above no Notification of Parents' Rights Poster was observe posted in a prominent, publicly accessible area at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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Licensee posted the Notification of Parents’ Rights Poster in a prominent, publicly accessible area near entrance. Defieciency cleared today.
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:Joel Segura
LICENSING EVALUATOR NAME:Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/03/2022 09:55 AM - It Cannot Be Edited


Created By: Elizabeth Larios On 08/02/2022 at 03:13 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: 08/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

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 C3 is missing LIC 700, and children (C1, C2, and C4) are missing LIC 627 in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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Licensee will provide LIC 700 to child C3 parents and children (C1, C2, and C4) parents with LIC 627 and will submit completed forms to San Jose Regional Office (SJRO) by POC date 08/09/2022.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in which child C1 is missing LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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Licensee will provide LIC 9227 to child C1 parents and will submit completed form to San Jose Regional Office (SJRO) by POC date 08/09/2022.
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:Joel Segura
LICENSING EVALUATOR NAME:Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


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