<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354417794
Report Date: 06/24/2024
Date Signed: 06/24/2024 11:55:02 AM

Document Has Been Signed on 06/24/2024 11:55 AM - 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:JIMENEZ ROA, ELVAFACILITY NUMBER:
354417794
ADMINISTRATOR/
DIRECTOR:		ELVA JIMENEZ ROAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 207-9622
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 0DATE:
06/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:44 AM
MET WITH:Jimenez Roa, ElvaTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 6/24/24, at 9:45 AM, Licensing Program Analyst (LPA), Doni Fici, met with Applicant, Jimenez Roa, Elva, for announced pre-licensing inspection. The purpose of today's inspection is to ensure the home is in compliance with Title 22 California Code of Regulations. Upon arrival, LPA was admitted into the home by the Applicant's Spouse and toured inside and outside during todays inspection.

The Applicant stated the adults, over the age of 18, residing in the home is her spouse, and two (2) daughters. The Applicant has two minor children living in the home. LPA advised that children living in the home will be included in the home ratio and capacity until they turn 10 years of age. The hours of operation for the family child care home (FCCH) will be Monday - Friday, 6:00 AM-5:30 PM and the Applicant is planning to offer care for children ages five (5) months to 13 years old. The Applicant has submitted a rental agreement for the home and will purchase liability insurance for the day care. LPA advised the Applicant to provide parents with Affidavit Regarding Liability Insurance (LIC282) upon registration until liability insurance is purchased in the future.

The 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, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA toured inside the home and observed sufficient materials and play equipment for day care children. The front of the home is properly set-up for caring for infants including soft materials covering the floor, toys, small climbing structures, and a baby changing table. Off limits to the inside the home include: three bedrooms, bathroom and garage...


Continued on Page 2...
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: JIMENEZ ROA, ELVA
FACILITY NUMBER: 354417794
VISIT DATE: 06/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Off limits to the outside of the home include: the sides of the backyard. LPA advised if there are changes to the on/off limits of the home to submit an updated facility sketch (LIC999A) to the San Jose Regional Office. There is a working telephone (cell phone) at the FCCH. The Applicant currently has one crib and 11 mats for children's napping. LPA advised that mattress sheets should be changed between infants, if the crib is shared, and infant sheets shall be washed daily.

The Applicant states that she will provide medication and Incidental Medical Services to children on a case by case basis. The Applicant states that all food/formula will be provided by the parents of children enrolled and she will prepare and warm food as needed at her home. Children will bring water in water bottles if needed. The Applicant has two high chairs available for feeding infants. LPA observed kitchen knives properly stored inaccessible to children. LPA advised reviewing storage of materials in kitchen/bathroom cabinets if the restroom is needed by older children in care. There are no firearms in the home and LPA advised Applicant that all firearms and ammunition should be locked and stored separately.

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: http://www.ada.gov/childqanda.htm

The Applicant is planning to primarily care for infants and has a baby changing pad, waste bin with a tight-fitting lid, and proper storage for diapers and wipes. There is a sink that is easily accessible in the kitchen for use, if needed.

The Applicant states that she will use the outdoor space for caring for children. LPA advised that if she does not plans to use outdoor space in the future, to submit an updated facility sketch (LIC999A).

LPA observed fully charged 2A10BC fire extinguisher, functioning smoke detector and carbon monoxide detector. LPA advised completing annual maintenance for the fire extinguisher. The Applicant was provided fire/emergency disaster drill log and was advised drills should be completed every 6 months.
Continued on Page 3...
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: JIMENEZ ROA, ELVA
FACILITY NUMBER: 354417794
VISIT DATE: 06/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The Applicant states that for discipline of the children, she will use redirection and 1:1 time with the child as needed. LPA advised that if utilized, the recommended duration for "time out" is 1 minute per year of age for the child. The Applicant understands that children's personal rights should not be violated; including no corporal punishment. Children should not be left for extended periods of time in furniture such as a high chair or play pen.

LPA discussed isolation of sick children with the Applicant and she states that if a child were to start feeling sick at her home that she would isolate the child with a napping mat, until the parent/guardian arrives to pick-up. LPA discussed isolation strategies, such as using a baby gate, and utilizing the restroom if the child's symptoms need close restroom access. LPA observed the Applicant has a first-aid kit, and thermometer, available in her home.

LPA additionally discussed supervision of children, unusual incidents (LIC624B), and requirements for additional staff/ adults living in the home. The Applicant states that she plans to transport children. The Applicant additionally understands that she must be home at least 80% of the time FCCH is open.

LPA reviewed small family child care home capacity requirements with the Applicant and provided copy of 102416.5 Staffing Ratio and Capacity from California Code of Regulations. The Applicant is not planning to care for more than 14 children at any time. There should never be more than four infants, children under two years of age, present at the FCCH.

LPA reviewed with the Applicant 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 required postings with Applicant and provided copies of Parents Rights bulletin (PUB394) and Earthquake Preparedness Checklist (LIC9148). LPA discussed Provider Information Notices (PINs). LPA additionally reviewed CCLD website and online annual fee payment.

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 platform.

Continued on Page 4...

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: JIMENEZ ROA, ELVA
FACILITY NUMBER: 354417794
VISIT DATE: 06/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.

LPA discussed the safe sleep regulations with the Applicant and provided 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.



The Applicant 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.

Exit interview conducted with Applicant, and report was reviewed and provided to the Applicant, Jimenez Roa, Elva

LPA advised the Applicant that a Large FCCH license will be issued pending manager review and approval.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4