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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409518
Report Date: 09/09/2022
Date Signed: 09/09/2022 11:07:08 AM

Document Has Been Signed on 09/09/2022 11:07 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:MEDINA, VICTORIAFACILITY NUMBER:
434409518
ADMINISTRATOR:MEDINA, VICTORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 904-8995
CITY:SAN JOSESTATE: CAZIP CODE:
95110
CAPACITY: 14TOTAL ENROLLED CHILDREN: 1CENSUS: 1DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Victoria MedinaTIME COMPLETED:
11:30 PM
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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. Licensee lives with her Mother, Esther Sierraz and minor Daughter. There was one day care infant present at the time of LPA’s arrival. Hours of operation are Monday - Friday from 8:00 AM to 4:30 PM.

LPA toured the indoor or and outdoor areas of the home. Fire drills are conducted are and logged. Last entry was 8/1/22. 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 bedroom and bathroom, first bedroom (next to entry) 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 9/9/2022:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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: MEDINA, VICTORIA
FACILITY NUMBER: 434409518
VISIT DATE: 09/09/2022
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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 Indiviidual Infant Sleeping Plan 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 9/9/2022:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
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: MEDINA, VICTORIA
FACILITY NUMBER: 434409518
VISIT DATE: 09/09/2022
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Licensee has a current CPR and First Aid card that expires on 11/11/23.

Licensee's Mandated Reporter Certificate expires 7/21/24.

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 NOT 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: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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