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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354417784
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:08:42 PM

Document Has Been Signed on 05/03/2024 12:08 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:BASURTO, OFELIAFACILITY NUMBER:
354417784
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
05/03/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Ofelia BasurtoTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Martha Jimenez-Villanueva (LPA) and Belinda Vall (LPM) conducted an announced pre-licensing relocation inspection today. LPA met with Ofelia Basurto applicant and her fingerprint cleared husband Alejandro, and explained the nature of today's inspection to her. Applicant's husband Alejandro was present today and their two children, one preschooler and one infant. Applicant was reminded any children residing in the home, including the assistant provider's children under the age of 10 and present will count for the ratio capacity.

The days and hours of operation will be Monday to Friday from 6:00 AM to 5:00 PM. The applicant understands that the children cannot stay in the home for more than 24 hours. Applicant has completed her Preventative Health and Safety Child Care Training included the lead poisoning training on 02/28/2023. Applicant's pediatric CPR and First Aid certifications are current and will expire on 03/04/2025. Applicant has completed her Mandated Reporter Training on 03/11/2023 and will expire in 03/11/2025. A copy of the lease/rental agreement was submitted as proof for 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 home is a two story home. LPA observed there is a central heater and air conditioning. LPA observed there are no bodies of water. LPA observed the home does not have a fireplace. LPA observed there are barricaded stairs inside the home. Off limits areas in the home are: the second floor which includes master bedroom and bathroom, two bedrooms, a bathroom and laundry room. On the first floor: the attached garage. The backyard has artificial grass and applicant states will use for outdoor activities. On limits: All the entire first floor which include one bedroom, one bathroom, living room and kitchen. LPA observed there are no pet animals in the home. LPA observed applicant has a fully charged fire extinguisher 3A40BC in the home, and a combo smoke and carbon monoxide detector operable. Applicant understands that prior to making any change related to the on or off limits must be reported to licensing prior to using.

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 05/03/2024 continues on page 2.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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: BASURTO, OFELIA
FACILITY NUMBER: 354417784
VISIT DATE: 05/03/2024
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***** Report dated 05/03/2024 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.ccld.ca.gov provided to applicant.

PIN 22-05-CCP Page Eight. LPA also discussed "zero tolerance" related regulations with the applicant. LPA observed proof of immunization required for the applicant.

A review of staff records on 05/01/2024 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.
Ofelia Basurto 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.

Because the Ofelia Basurto rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

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: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

***** Report dated 05/03/2024 continues on page 3.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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: BASURTO, OFELIA
FACILITY NUMBER: 354417784
VISIT DATE: 05/03/2024
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***** Report dated 05/03/2024 continues from page 2.

LPA reviewed with Ofelia Basurto 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.



LPA discussed the safe sleep regulations with Ofelia Basurto and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep, as an additional resource. LPA also informed Ofelia Basurto 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 this date, 03/13/2024, 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.


Ofelia Basurto was informed of the MyChildCarePlan.org site, 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.

Exit interview conducted and report was reviewed with the Ofelia Basurto 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-care-licensing/subscribe and select the Child Care option to receive email communication.

This facility is licensed effective today, 05/03/2024.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Martha Jimenez-Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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