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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274417824
Report Date: 07/01/2024
Date Signed: 07/01/2024 12:07:53 PM

Document Has Been Signed on 07/01/2024 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:ANDRADE CAMPOS, KITZIAFACILITY NUMBER:
274417824
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/01/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kitzia Andrade CamposTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an announced pre-licensing inspection to the home today. LPA met with Kitzia Andrade Campos, applicant, and explained the nature of today's inspection to her. Applicant stated that the adults that reside in the home are: applicant Kitzia, and her boyfriend Ernesto. Also, in the applicant's home reside applicant's minor children: ages 13, and 5 years old.
The days and hours of operation will be Monday to Saturday from 4:00 AM to 6:00 PM. The applicant understands that the children cannot stay in the home for more than 24 continue hours. Applicant has completed her Preventative Health and Safety Child Care Training included the lead poisoning training on 10/15/20. Applicant's pediatric CPR and First Aid certifications are current and will expire on 10/28/24. Applicant has completed the Mandated Reporter training on 2/28/24. The applicant owns the home and a copy of the property deed document is in file as proof of control of the property. Applicant states does not have liability insurance for a family child care home (FCCH) and will use the Affidavit regarding liability insurance for Childcare (form LIC 282).
LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed the FCCH is located in a single-story-house. LPA observed there is a barricaded wall heater in the home. LPA observed there are no stairs inside the home or bodies of water. Off limits areas in the home are: 2 bedrooms and the attached garage. LPA observed the home has fenced side and back yards. Off limits areas outside are: One storage shed located in the back yard, and the right side yard. Applicant stated will use the back yard as playground for the children in care. LPA observed there are no animal pets in the home. LPA observed applicant has a 3A40BC fire extinguisher last time serviced on 9/20/23, and at least one working smoke/carbon monoxide (CO) detector in the home. Applicant understands that prior to making any change related to the on or off limits must be reported to Licensing Program.
The applicant states that there are no weapons in the home. Applicant understands that cleaning products, toxic agents, medications, and sharp objects shall not be accessible to children. LPA reminded applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.
********************* Report dated 7/01/24 continues on page 2.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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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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: ANDRADE CAMPOS, KITZIA
FACILITY NUMBER: 274417824
VISIT DATE: 07/01/2024
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******Report dated 7/01/24 continues from page 1.

Forms of discipline applicant will use: Communication with children and redirection. Applicant understands that children's personal rights should not be violated, including no corporal punishment. Isolation of sick children, supervision of children, capacity options for a small license, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed applicant that fire/disaster drills must be practiced at least once every 6 months and documented.
Department website www.cdss.ca.gov provided to applicant.

Applicant understands that children residing in the home count as part of the capacity of her license until they reach the age of ten years old.
LPA discussed the requirements of AB 633 with the applicant. LPA also discussed "zero tolerance" related regulations with the applicant.
LPA observed proof of immunization for measles, pertussis and influenza are in the applicant's file.

A review of staff records on 6/18/24 indicates that all the adults residing in the home or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

The applicant provided proof of control of property.

LPA reviewed with applicant, the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant. 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) or (800) 514-0383 (TTY) and link to publication:

Report dated 7/01/24 continues on page 3.

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

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
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: ANDRADE CAMPOS, KITZIA
FACILITY NUMBER: 274417824
VISIT DATE: 07/01/2024
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******Report dated 7/01/24 continues from page 2.

Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. Review of records to be maintained - Child Care Centers.

LPA discussed the safe sleep regulations with applicant 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.

LPA also informed applicant, 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.

On the date, 6/17/24 the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Exit interview conducted and report was reviewed with the applicant Kitzia Andrade Campos in Spanish.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

The applicant currently holds a FCCH license at 1154 Acosta St #5, Salinas, CA 93905. Applicant understands that she can not hold two licenses at a time. The current license will be closed before a new license is granted.

The applicant was informed that a small Family Child Care Home license will be approved pending on the following:


1) Submit proof of making inaccessible the storage shed in the back yard.
2) Approval from a manager of the Licensing Program.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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