434403446-6-5-2024-07-CC-SCHN-D5XU2L-20240605151207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434403446
Report Date: 06/05/2024
Date Signed: 06/05/2024 03:12:16 PM

Document Has Been Signed on 06/05/2024 03:12 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:	AMBROCIO-GACAYAN, PATRICIA		FACILITY NUMBER:	434403446
ADMINISTRATOR/ DIRECTOR:	PATRICIA AMBROCIO-GACAYAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 251-4728
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95133
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 2	DATE:	06/05/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Patricia Ambrocio-Gacayan		TIME VISIT/ INSPECTION COMPLETED:	03:30 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	Page 1. On 6/5/24 Licensing Program Analyst (LPA) Sheena Chin conducted an unannounced annual inspection at the facility. LPA met with the licensee, Patricia Ambrocio-Gacayan, and explained the nature of today’s inspection. Present during today’s inspection were the licensee, and 2 children (1 one year old, 1 almost 3 years old) in the facility. Days and hours of operation are Monday to Friday, 7:30am to 5:30pm. The adults that reside in the home is the licensee. The licensee stated that she had a rifle locked in off-limit area, there was no ammunition and firing pins were stored and locked separately from rifle. The licensee stated she owned the home. Observation LPA observed that required postings were posted. LPA, along with the licensee, toured the inside and outside of the home. The facility has a full charged fire extinguisher, 2A10BC. Carbon monoxide and smoke detectors are working properly. The facility is a multilevel home. The off-limit areas in the facility are third level, formal dining room on the second level and garage on the first level. All disinfectant, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible. In the backyard LPA observed a swimming pool with cover but without fence. The licensee stated that the pool has been in the backyard when she moved in and that the pool had a commercial vinyl cover, which was strong enough to hold the licensee’s weight. The licensee stated that in order to open the pool cover special tools were needed to insert into the roller, which was locked in a box. LPA observed that there are toys for children inside and outside of the house. LPA conducted CARE Tools for this annual inspection, which include Physical Plant, Care and Supervision, Facility Administration, Records, Staffing Ratio and Capacity, Personnel Rights for compliance with all licensing statutes, regulations, and interim licensing Standards, and results were documented on the tool. continue to page 2.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

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: AMBROCIO-GACAYAN, PATRICIA	FACILITY NUMBER: 434403446
	VISIT DATE: 06/05/2024

NARRATIVE

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Records review
The Licensee has current CPR and First Aid certifications expiring 6/25/24. The Licensee has the child abuse training certificate, expiring 5/31/26. LPA reviewed the fire and disaster drills log which is to be done at least once every six months. The last drills were conducted on 4/25/24. LPA reviewed children’s files. Immunization records are maintained and updated in form PM 286. LPA observed Notification of Parents’ Rights is in each child’s file, and 15 min. sleeping check logs for infants under 2 years old.

During today’s inspection, all adults present or residing in the home have criminal record clearances required by the Department. Licensee was reminded that all adults 18 and over living or working in the home, 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.

Discussion

Supervision of children was discussed with Licensee, who understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options. Licensee states that she does not transport children via vehicle but she understands that children cannot be left in parked vehicles unattended at any time.

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 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.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: AMBROCIO-GACAYAN, PATRICIA	FACILITY NUMBER: 434403446
	VISIT DATE: 06/05/2024

NARRATIVE

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Discussion
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: https://www.ada.gov/resources/child-care-centers/.

The Licensee 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.

Deficiency
No regulatory violations were observed during today’s inspection.

Further questions
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@dss.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/inspection-process.

Exit
During the exit interview, the licensee, Patricia Ambrocio-Gacayan, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
Exit interview conducted and report was reviewed with the licensee, Patricia Ambrocio-Gacayan.
Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC809 (FAS) - (06/04)

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