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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409518
Report Date: 06/27/2024
Date Signed: 06/28/2024 08:20:25 AM

Document Has Been Signed on 06/28/2024 08:20 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
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: 4CENSUS: 3DATE:
06/27/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:26 AM
MET WITH:Victoria MedinaTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 3 Year inspection. LPA met with Licensee Victoria Medina and explained the reason for the inspection. Present during today's inspection were Licensee, her minor child, who is under 10 years old, and two daycare children, whom were both infant age.

The required postings, such as license and notification of parent's rights were observed to be posted. The hours of operation are Monday through Friday 7AM to 5PM. Licensee uses her cell phone.

LPA toured the inside and outside of the home. The off-limit areas of the home are the bedroom next to the front door and master bedroom. The bathroom, kitchen, and the bedroom adjacent to the dining room is currently not being used for children, but Licensee will use it if she cares for school-age children. LPA did not observe any children in any of those areas during today's inspection. LPA observed that the door the leads to the hallway was closed and there is a gate to make the kitchen area off-limits. LPA discussed with Licensee that any medication, knives, or graters, need to be inaccessible. There are no stairs or fireplace in the home. There are toys for the children. There is a fire extinguisher and smoke detector. LPA discussed with Licensee that the fire extinguisher needs to be serviced every year or proof of purchase of a new fire extinguisher is needed. The last fire/disaster drill was completed on 05/15/2024. Licensee stated that there are no weapons, such as firearms, stored on the premise. Licensee has a pet.

The backyard is used and is fenced. The off-limit area outside is the basement. LPA discussed with Licensee that the door to the basement needs to be closed. There is a playstructure in the backyard, which is not anchored to the ground. LPA discussed with Licensee that any playstructure or climbing structure needs to be anchored to the ground. There is no bodies of water observed during today's inspection.
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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 06/27/2024
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-----------------continuation of 809 dated 06/27/2024 page 1---------------------

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-andresources/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. LPA provided Licensee with PIN-20-24-CCP. Licensee stated that she has a play yard to place sleeping infant. LPA discussed with Licensee that if a infant falls asleep in the swing or her arms that they need to be transferred to either a crib or play yard. LPA also discussed that each infant needs to have their own crib or play yard.

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/.

Licensee does transport children and has a valid driver's license. Licensee understands that children cannot be left alone and unattended in parked vehicles.

LPA reminded Licensee that all food containers brought from home need to have the child's name. One of the child had a lunch bag that has their name on.

A copy of the facility roster was obtained during today's inspection. LPA discussed with Licensee that roster needs to be updated as she enrolls children. One child's files was reviewed during today's inspection. Parents filled out required forms during today's inspection. LPA discussed with Licensee that she needs to have paperwork completed for children and in file. LPA also discussed and showed Licensee where she can obtain translated forms on the Licensing website.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
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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: 06/27/2024
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Licensee has a valid CPR/1st Aid, which expires on 01/2026. Licensee stated that she completed the mandated reporter training, but was unable to find certificate. The mandated reporter training can be completed on www.mandatedreporterca.com.

The adults 18 and over living in the home are Licensee and her mother. Licensee also has one minor child. All adults have cleared criminal record and child abuse index. 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.

Licensee will submit the following:
- proof that the play structure is taken down by 07/19/2024
- Mandated Reporter training certificate
- carbon monoxide detector
- measles
- proof of play yard
- 15 minute sleep check
- LIC 279

As a result of this inspection, Type B citations were issued. Exit interview conducted and report was reviewed with Licensee Victoria Medina. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
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Document Has Been Signed on 06/28/2024 08:20 AM - It Cannot Be Edited


Created By: Samantha Yip On 06/27/2024 at 03:28 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: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(i)
Infant Safe Sleep
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. Licensee stated that the play yard in the basement.
POC Due Date: 07/12/2024
Plan of Correction
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By POC 07/12/2024, Licensee will submit proof that there is a play yard.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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By POC 08/12/2024, Licensee will submit Mandated Reporter training certificate to Licensing.
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


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Document Has Been Signed on 06/28/2024 08:20 AM - It Cannot Be Edited


Created By: Samantha Yip On 06/27/2024 at 03:28 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: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. Licensee has not documented the name of the child, date, and the time checked when infant is napping.
POC Due Date: 07/12/2024
Plan of Correction
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By POC 07/12/2024, Licensee will complete sleep check and document the name, date, and time checked. Licensee will submit sleep log to Licensing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


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Document Has Been Signed on 06/28/2024 08:20 AM - It Cannot Be Edited


Created By: Samantha Yip On 06/27/2024 at 04:13 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: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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By 07/12/2024, Licensee will submit proof of purchase of carbon monoxide detector.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


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