434402958-11-1-2024-07-CC-LFII-DALQFW-20241101120833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434402958
Report Date: 11/01/2024
Date Signed: 11/01/2024 12:25:30 PM

Document Has Been Signed on 11/01/2024 12:25 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:	ANAYA-BUENO, JOHANNA		FACILITY NUMBER:	434402958
ADMINISTRATOR/ DIRECTOR:	ANAYA, JOHANNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 506-4977
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95110
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 4	DATE:	11/01/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:55 AM
MET WITH:	Johanna, Anaya-Bueno		TIME VISIT/ INSPECTION COMPLETED:	12:35 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 11/1/24, at 8:55 AM, Licensing Program Analyst (LPA) Liridon Fici (Doni) arrived unannounced to conduct an Annual inspection and was greeted by Licensee, Johanna, Anaya-Bueno. LPA also informed Licensee the purpose of today’s visit. During visit, there were two (2) staff and four (4) children present. Licensee stated that her, her husband, and her daughter are the adults residing at the home. All are fingerprint cleared and associated to the facility. LPA observed one child child under 2 years old, and 3 children over 2 years old. The day care is located in the living room of the house. Parents will enter from the front of the house. The front part of the home is off limits from the day care. The home has no stairs going up to the second floor. Days and hours of operation are Monday - Friday from 7:00 AM to 5:00 PM. LPA reviewed Fire/Disaster drill log during today's inspection was conducted on 8/12/24. LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee’s has a working cell phones in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. The backyard is enclosed by a fence. Off limit areas inside Licensee's home: Bedroom 1, 2, and 3, laundry room, and the front of the house. Off limits to the outside home include: left side of the backyard. LPA toured the backyard area and observed the backyard area is adequately fenced and there are no bodies of water. There is a designated area in the living area where the couch is located where child(ren) can be isolated if exhibiting any signs of illness until the child's parent(s) pick them up. Continue on Lic809-C page 2...

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

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: ANAYA-BUENO, JOHANNA	FACILITY NUMBER: 434402958
	VISIT DATE: 11/01/2024

NARRATIVE

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Licensee provides breakfast, and lunch, along with snacks for the children in between. Licensee will accept outside food from parents and Licensee will prepare and cook meals for children. LPA observed a first aid kit in the day care. Staff stated that nobody smokes, and she understands that smoking is prohibited in the day care. LPA observed a fully charged 3A4BC fire extinguisher last time serviced on 11/16/2023, with working smoke and carbon monoxide detectors. The Licensee stated that there are no weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children.

LPA reviewed a selection of four (4) children's file and observed that parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification forms are in each file. LPA did not observe 15-minute sleep logs for an infant in care.

Licensee and Staff files were reviewed for the following records: Employee Rights (LIC9052), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). Licensee has a current Mandated Reporter Training and was conducted on 3/20/2025. Licensee has current Pediatric CPR/FIRST AID that was conducted on 11/11/2025. LPA informed Licensee that Mandated reporting and First aid/CPR is mandatory, and should be renewed every 2 years.

Incidental Medical services (IMS) policy was discussed. Licensee does not handle any medications. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417 and 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. Licensee does not currently have children who need medication.

LPA discussed the safe sleep regulations with licensee 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

Continue on Lic809-C page 3...

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

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: ANAYA-BUENO, JOHANNA	FACILITY NUMBER: 434402958
	VISIT DATE: 11/01/2024

NARRATIVE

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as an additional resource. LPA also informed Licensee 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.

Supervision of children was discussed with licensee, and she understands that she must be present in the home during day care hours and ensure that the children are always supervised. Licensee understands her capacity options and she understand that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

LPA discussed the requirements of AB 633 with the Licensee and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). 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. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

The licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

The following type B deficiencies was cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted with Licensee, and a copy of this review was reviewed and provided alone with appeal rights.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/01/2024 12:25 PM - It Cannot Be Edited

Created By: Liridon Fici On 11/01/2024 at 11:47 AM

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: ANAYA-BUENO, JOHANNA	FACILITY NUMBER: 434402958
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)

Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and record review, the licensee did not comply with the section cited above by not having current vaccine records maintained for child 2, 3, and 4 (C2, C3, C4) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Licensee agreed to submit a copy of Child 2, 3, and 4's vaccine to CCL by POC due date

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above by not conducting 15-minute sleep checks for child 4 (C4) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Licensee agreed to start conducting 15-minute sleep checks for C4, and to submit proof of sleep log to CCL by POC due date.

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:

Gladys Kuizon

LICENSING EVALUATOR NAME:

Liridon Fici

LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

LIC809 (FAS) - (06/04)

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