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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354415568
Report Date: 08/28/2024
Date Signed: 08/28/2024 09:41:31 PM

Document Has Been Signed on 08/28/2024 09:41 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:VALLE, SUSANAFACILITY NUMBER:
354415568
ADMINISTRATOR/
DIRECTOR:		VALLE, SUSANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 537-3713
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
08/28/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:57 PM
MET WITH:Valle, SusanaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 08/28/24 at 12:57 PM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee Susana Valle, for an annual inspection. Present with licensee were minor daughter who assists, with 1 child: one (1) Infant. Adults living in the home are licensee, her spouse Sigfredo and her two minor children ages 17 and 13 years old. Days and hours of operation are Monday through Friday 05:00 AM to 05:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 08/27/2024 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 Susana Valle was reminded that all 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 inspected inside and outside of single-story home. Licensee rents the home and Licensee states she has liability insurance for a family childcare home (FCCH). LPA observed a 3A40BC fire extinguisher last purchased/serviced on 04/09/2024. Carbon Monoxide and smoke detectors are operable. LPA observed no wall heaters. LPA observed a barricaded fireplace in the home. Licensee stated there are no firearms/weapons in the home. Sharp objects, medicines, poisons, and cleaning supplies are inaccessible to the children. Backyard is fenced. Off limits indoor: master bedroom, master bathroom, two bedrooms, and the attached garage. Off Limit outdoor: rear yard dog kennel used as storage, gated right side of house. Licensee states there are two dogs in the home that are with the day care children.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to her license. Licensee stated she does 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. Licensee left child care home to pick up 6 school age children and arrived back with them at 3:18 PM, One school age child is her 13 year old son.


Continues report dated 08/28/2024 pg. 1/3
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 08/28/2024 09:41 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 08/28/2024 at 03:54 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: VALLE, SUSANA
FACILITY NUMBER: 354415568

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatio, interview and record review, the licensee did not comply with the section cited above in last fire/disaster drill completed on 05/18/23, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Licensee will conduct a fire/disaster drill by close of business 09/13/24 and submit a copy of fire/disaster drill to the San Jose Regional Office by 09/13/24.

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:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2024 09:41 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 08/28/2024 at 03:54 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: VALLE, SUSANA
FACILITY NUMBER: 354415568

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in, Child 1 missing from roster, one school age child need to be removed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee will submit an updated roster of children by close of business 08/30/24 to the San Jose Regional Office.
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 observation, interview and record review, the licensee did not comply with the section cited above in, Child 1 does not have LIC 9227 on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee will submit a signed copy of LIC 9227 to the San Jose Regional Office by close business 08/30/24.
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:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


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: VALLE, SUSANA
FACILITY NUMBER: 354415568
VISIT DATE: 08/28/2024
NARRATIVE
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Continuation of report dated 08/28/2024 pg. 2/3

LPA observed a roster of the children that needs to be updated with Child 1. LPA observed a fire and disaster drill log last performed on 05/18/2023. LPA reviewed 5 children’s files and observed not all required documentation was in compliance. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was discussed. Child 1 missing LIC 9227. LPA observed licensee completed Mandated Reporter Training on 07/16/2024. Licensee has Pediatric CPR/1st Aid expiring on 01/20/2026. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is current for licensee, and all adults residing in the home.

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 currently. 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 Susana Valle and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] 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 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.

Continues report dated 08/28/2024 pg. 2/3
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 13 of 14
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: VALLE, SUSANA
FACILITY NUMBER: 354415568
VISIT DATE: 08/28/2024
NARRATIVE
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Continuation of report dated 08/28/2024 pg. 3/3

Licensee Susana Valle 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 Susana Valle, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Type B Deficiencies were cited today. 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 with the licensee Susana Valle.

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: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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