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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409518
Report Date: 10/01/2021
Date Signed: 10/01/2021 02:09:20 PM

Document Has Been Signed on 10/01/2021 02:09 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MEDINA, VICTORIAFACILITY NUMBER:
434409518
ADMINISTRATOR:MEDINA, VICTORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 904-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95110
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
10/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Victoria MedinaTIME COMPLETED:
02:18 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pete Hernandez conducted an unannounced Required 1 Year inspection at the home today. LPA met with Victoria Medina, Licensee, and explained the nature of today's visit to her. Also present today was licensee's Mother, Esther Sierraz. There were no day care children present at the time of LPA’s arrival. Hours of operation are Monday - Friday from 7:30 AM to 5:30 PM. The Licensee has 1 Six year old minor child living in the home.

LPA toured the indoor or and outdoor areas of the home. Fire drills are conducted are and logged. Last entry was 8/12/2021. The Licensee has a working telephone in the he home. LPA observed sufficient materials, toys, and play equipment for the day care children. Off limit areas in the home are the master bathroom and bathroom, first bedroom and cellar.

LPA observed a fully charged 2A10BC fire extinguisher. There is a working smoke & carbon monoxide detector in the home. LPA observed a fenced backyard. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, other similar items and poisons are inaccessible to children. All required forms are posted.


REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 10/1/2021:
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MEDINA, VICTORIA
FACILITY NUMBER: 434409518
VISIT DATE: 10/01/2021
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided, an updated Plan of Operation that includes 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

A review of staff records today 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 also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. 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 the Licensee. Licensee understands that she must be present in the home at least 80 percent of the hours the day care is in operation and ensure that the children are supervised at all times. The Licensee understands her capacity options. The Licensee states that she does not transport children and understands that children cannot be left in parked vehicles unattended at any time. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.

LPA informed Licensee that Licensing forms and Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov

LPA also discussed the required LIC9227 as it relates to care for infants.

LPA discussed and provided Safe Sleep Child Care information to the Licensee.
REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 10/1/2021:
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MEDINA, VICTORIA
FACILITY NUMBER: 434409518
VISIT DATE: 10/01/2021
NARRATIVE
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Licensee has a current CPR and First Aid card that expires on 12/12/21.

Licensee's Mandated Reporter Certificate is expired. Licensee will be required to update her certificate.

Type A language: Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with the licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Victoria Medina, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2021 02:09 PM - It Cannot Be Edited


Created By: Pietro Hernandez On 10/01/2021 at 12:27 PM
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: MEDINA, VICTORIA
FACILITY NUMBER: 434409518

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2021
Section Cited
HSC
1596.8662(b)(1)

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On or before March 30, 2018, a person who on, January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training […] and shall complete renewal […] every two years […] This requirement is not met as evidenced by:
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BY POC DUE DATE Licensee will complete the training and send a copy of the Certificate of Completion to Licensing Office. LPA provided the web address https://www.mandatedreporterca.com to access the required training.
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Per LPA's review of files, Licensee does not have Mandated Reporter Training per AB1207. Licensee stated she was unaware of the requirement. This poses a potential risk to the health and safety of children in care.
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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:Sandy Knight
LICENSING EVALUATOR NAME:Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2021


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