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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274417612
Report Date: 01/24/2024
Date Signed: 01/24/2024 12:07:04 PM

Document Has Been Signed on 01/24/2024 12:07 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CRUZ CRUZ, NANSYFACILITY NUMBER:
274417612
ADMINISTRATOR:NANSY CRUZ CRUZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 512-6295
CITY:CASTROVILLESTATE: CAZIP CODE:
95012
CAPACITY: 14TOTAL ENROLLED CHILDREN: 3CENSUS: 1DATE:
01/24/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nansy Cruz CruzTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Fermin Campos-Jaramillo conducted an unannounced annual inspection to the home today. LPA met with Nansy Cruz Cruz, Licensee, and explained the nature of today's inspection to her. LPA observed licensee was providing care and supervision only to an infant. Days and hours of operation are Monday to Friday from 6:00 AM to 5:30 PM and Saturdays 6:00 AM to 3:00 PM. The adults that reside in the home are the Licensee and her husband Jesus. Also in the home reside Licensee's minor children ages 17, 13, 10, and 5 month old. Licensee's certifications for CPR and First Aid are current and will expire on 9/01/25 and for Jesus on 4/4/25.

LPA toured the indoor and outdoor areas of the home during today's inspection. LPA obtained a copy of the Child Care Facility Roster today and it is complete. LPA reviewed three children's files and are complete. The last fire and disaster drill was documented on 1/22/24. The Licensee has a working telephone in the home. 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. LPA did not observe any wall heaters inside the home. There are no stairs or bodies of water in the home. Off limit areas in the home: Three bedrooms and one bathroom. Also off limits is the attached garage and the laundry area in the garage. Off limit areas outside the home: one locked storage shed in the back yard and the side yards. LPA observed licensee has two dogs kept on the off limits area. Licensee stated the dogs are vaccinated. The home has fenced back yard used for the children in care for outdoor activities.

LPA observed a fully charged 3A40BC fire extinguisher last serviced on 1/16/24, working smoke and carbon monoxide detectors, and no bodies of water. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children.

*************Report dated 1/24/24 continues on page 2
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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Document Has Been Signed on 01/24/2024 12:07 PM - It Cannot Be Edited


Created By: Fermin Campos-Jaramillo On 01/24/2024 at 11:24 AM
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: CRUZ CRUZ, NANSY
FACILITY NUMBER: 274417612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

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. Licensee is not documenting the sleep of her own infant on a log , which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Licensee shall submit to licensing Program before 2/08/24 a copy of the log (provided to licensee) documenting the infant sleep for the period 1/24//24 to 2/06/24. Licensee will continue documenting the infants sleep until they reach the age of two years old.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CRUZ CRUZ, NANSY
FACILITY NUMBER: 274417612
VISIT DATE: 01/24/2024
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********************************Report dated 1/24/24 continues from page 1.
LPA observed the Licensee has in file proof of immunization for pertussis, measles, and influenza as required by the SB792 for herself and for her helper Jesus.
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 14 children in the home at any time, and a helper must be present when more than 8 children are present and ratio (age of the children) must be observed. Licensee understands that in absence of a helper her license is reduced automatically to 8 children and ratio must be observed as well. Licensee understands that her own children count as part of the capacity of the license until them reach the age of 10. The Licensee states that she does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.
Department website: www.ccld.ca.gov provided to Licensee.

LPA observed the Licensee and her helper Jesus have renewed the Mandate Reporter training on 6/13/22 and 3/21/23 respectively. Licensee understands the training shall be renewed every two years. LPA referred the Licensee to the training website www.mandatedreporterca.com for additional information on the online training.
A review of staff records on 1/19/24 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
Licensee was reminded that all the adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource.

*****************************Report dated 1/24/24 continues in page 3

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CRUZ CRUZ, NANSY
FACILITY NUMBER: 274417612
VISIT DATE: 01/24/2024
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********Report dated 1/24/24 continues from page 2.
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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Nansy Cruz confirmed that there are no Registered Sex Offenders living in the facility.



Exit interview conducted and report was reviewed with the licensee Nansy Cruz.
There was a type B deficiency cited today.

Failure to comply with the Plan Of Corrections (POC) by the due date on LIC809D shall result in an immediate civil penalty of $100 per day per each deficiency.

A notice of site visit was handed to licensee and must remain posted for 30 days.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
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