430758279-6-14-2023-07-CC-FRAA-CSSM8M-20230614092321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430758279
Report Date: 06/13/2023
Date Signed: 06/14/2023 09:23:26 AM

Document Has Been Signed on 06/14/2023 09:23 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	GUTIERREZ, IVONNE		FACILITY NUMBER:	430758279
ADMINISTRATOR:	IVONE GUTIERREZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	4084393700
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 2	DATE:	06/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Ivonnw Gutierrez		TIME COMPLETED:	04:50 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 06/13/2023 at 2:10pm, Licensing Program Analyst (LPA), Farida Raja, conducted an unannounced 1- year annual inspection. LPA was granted access to the home by Licensee, Ivonne Gutierrez, and explained the nature of today’s inspection. Present in the home were licensee and two school age children. Licensee was operating within the ratio and capacity requirements of her license. Days and hours of operation are Monday to Friday, 6:00 am to 6:00 pm. LPA observed all required posted materials in the indoor play room of the home. This facility has one waiver that allows the wood burning stove in the living room not to be screened. Licensee was in compliance with the conditions of the waiver. The adults that reside in the home are Licensee, licensee’s adult son and daughter. LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home (408-439-3700). LPA observed sufficient materials, toys, and play equipment for the day care children. Furniture, such as tables, chairs, feeding chairs and shelves, are in good condition. The floors were free of tripping hazards with toys put away on shelves. The home has central heating/cooling and ventilation for comfort of children. In use areas inside the home: indoor playroom and hall bathroom. There are no stairs inside the home. Off limit areas outside the home: left side section including the storage shed. Backyard is fenced, both sides of the home are gated and no bodies of water were observed. The outdoor space and play equipment were observed to be maintained in safe condition and free of hazards. LPA observed that the bathroom used by children was in operating condition. Toilets and faucet are clean and operable. The shower area is free on any hazards. LPA observed a fully charged 3A40BC fire extinguisher in the playroom area and working smoke/carbon monoxide detectors. The Licensee states that she does not have any weapons or pets in the home. All detergents, cleaning compounds, medications, sharp objects and other similar items are stored inaccessible to children. Licensee understands that smoking is prohibited in the home. Continued on Page 2

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GUTIERREZ, IVONNE	FACILITY NUMBER: 430758279
	VISIT DATE: 06/13/2023

NARRATIVE

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Drinking water is readily available for children in the home via bottles or disposable water cups. Licensee states that she provides breakfast, lunch, dinner (occasionally) and two snacks to the children in care.

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Fire/disaster drill was conducted on 06/08/2023. LPA obtained copy of children's roster. Children file review was completed and found to be current and up to date. Two (2) school age children’s files were reviewed during today's inspection. Licensee does not have liability insurance for the day care and issues the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282). LPA reviewed one infant child's file and the file was complete with the required forms, including the Individual Infant Sleeping Plan (LIC 9227). LPA reviewed 15-minute sleep logs for infant in care.

A review of staff records 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 reviewed two staff files (Licensee and Mother/Assistant) and the files were complete with the required forms. Licenseeand assistant have current Pediatric CPR/First Aid certification with an expiration date of 02/01/2025. Licensee and Assistant's Mandated Reporter Training expires on 01/10/2024.

Licensee was reminded that all adults 18 and over living or working in the home, 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. 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.

Supervision of children was discussed with Licensee, and she understands that she or a qualified adult must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time and a qualified assistant must be present. Licensee understands in absence of a helper her license capacity is reduced to 8 and ratio (age of the children) must be observed. Licensee states that she does not transport any day care children.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GUTIERREZ, IVONNE	FACILITY NUMBER: 430758279
	VISIT DATE: 06/13/2023

NARRATIVE

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LPA discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. A $500 immediate civil penalty and $100 per day violation until corrected is assessed for serious violations such as absence of supervision, accessible bodies of water, accessible firearms, refused entry of licensing staff, presence of an excluded person, and violations that result in illness or injury. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Licensee states that she does not administer any medications to the day care children at this time. Incidental Medical Services (IMS) policy was discussed. LPA provided a copy of PIN 22-02. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding Americans with Disabilities Act (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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email to inspectionprocess@dess.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/process.

As a result of today's inspection, there were no deficiencies cited.

Exit interview conducted and report was reviewed with the Licensee, Ivonne Gutierrez

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC809 (FAS) - (06/04)

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