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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354415929
Report Date: 04/15/2020
Date Signed: 06/05/2024 02:56:40 PM

Document Has Been Signed on 06/05/2024 02:56 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:LEZAMA VILLAGOMEZ, MARIAFACILITY NUMBER:
354415929
ADMINISTRATOR:MARIA LEZAMA VILLAGOMEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 297-4731
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
04/15/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Maria Lezama VillagomezTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Deanna Villagrana conducted a tele-visit with applicant Maria Lezama Villagomez to conduct an announced pre-licensing/change of location inspection. The adults that reside in the home are the licensee, her husband, adult daughter and 9 year old son.

Days and hours of operation will be Monday - Friday from 6:00 AM to 6:00 PM. Applicant has completed her Preventative Health and Safety Child Care Training on 01/25/2020. Applicant's CPR and First Aid certifications are current and expire on 03/14/2022. Applicant owns the home. LPA toured the indoor and outdoor areas during today's visit. There are no stairs in the home. LPA observed a barricaded fireplace in the day care area. Off limit areas inside the home: master bedroom/bath, two bedrooms, walk in pantry and attached garage. LPA observed a fully charged 3A40BC fire extinguisher, working combo smoke and carbon monoxide detector. LPA observed the backyard was fenced and observed a swimming pool that has a locked 6 ft. fence making it inaccessible to children. Outdoor play area will be in designated area only. Off limit areas outdoor: is swimming pool area and locked storage on left side of the home. Applicant states that there are no weapons or animals in the home. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.

A review of staff records on 04/02/2020 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 reminded Applicant 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.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2020
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: LEZAMA VILLAGOMEZ, MARIA
FACILITY NUMBER: 354415929
VISIT DATE: 04/15/2020
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Forms of discipline used by Applicant: talking to 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, 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.

LPA discussed the requirements of AB 633 with the Applicant and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Applicant understands the requirements. LPA also discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 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. Incidental Medical Services (IMS) policy was discussed. SB 792 Immunization Requirements was also discussed. Applicant's immunization records are on file. Licensee completed Mandated Reporter training on 02/24/2020.

The pre licensing self assessment guide was reviewed with licensee. Department's website: www.ccld.ca.gov to obtain forms and regulations CCR, Title 22 was provided. LPA also discussed the requirements of AB 633 to licensee and Acknowledgement of receipt of Licensing Reports (LIC 9224). Zero Tolerance with $500 civil penalty also explained to applicant.

LPA conducted an exit interview with the Applicant and advised her that a large Family Child Care Home license is approved pending managers approval.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2020
LIC809 (FAS) - (06/04)
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