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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416747
Report Date: 10/05/2021
Date Signed: 10/06/2021 08:37:45 AM

Document Has Been Signed on 10/06/2021 08:37 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:FERNANDEZ DE HARO, GLADIZFACILITY NUMBER:
434416747
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
10/05/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Gladiz Fernandez De HaroTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an announced pre-licensing inspection. LPA met with Applicant Gladiz Fernandez De Haro and explained the reason for the inspection. The purpose of this inspection is Applicant requested a change of location. Applicant is currently licensed at 9050 Kern Avenue #C2, Gilroy, CA 95020 (license number #434414547).

Licensee does have a board to post required posting, which include but not limited to Earthquake Preparedness and Notification of Parent's Right. Licensee stated that she will complete Earthquake Preparedness checklist. LPA also observed COVID posters. The hours of operation are Monday through Friday 7AM to 5:30PM. There is working phone in the home. Applicant owns the home and will submit control of property to Licensing by 10/15/2021. Applicant does have daycare insurance and understands that she needs the Affidavit Regarding Liability Insurance to inform parents that she does not have a daycare insurance.

LPA toured the inside and outside of the home with Applicant Gladiz. The off-limit areas of the home are the entire upstairs, laundry room, garage, the right side of the backyard, and the shed outside. Applicant stated that she submit updated LIC 999A: Yard to Licensing. LPA reminded Licensee to ensure that all doors to off-limit areas are closed. There are stairs in the home, which are barricaded. There is a gas fireplace, which has a glass cover and is locked. LPA observed that there is sufficient amount of toys for children in care. All furniture were observed to be age-appropriate. All disinfectants, cleaning supplies, and other items that could pose a risk was inaccessible. There is a fully charged fire extinguisher, functioning smoke detector, and carbon monoxide detector. Applicant stated that there are no weapons, such as firearms, stored in the home.

----------------------CONTINUES ON 809 DATED 10/05/2021 PAGE 2-----------------------------
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: FERNANDEZ DE HARO, GLADIZ
FACILITY NUMBER: 434416747
VISIT DATE: 10/05/2021
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----------------------CONTINUATION OF 809 DATED 10/05/2021 PAGE 1-----------------------

The backyard will be used and is fenced. LPA observed that there are two gaps in the fence. Applicant stated that she will have her gardener fix it this weekend and send proof to Licensing. Applicant stated that she will put a fence in front of the gap until her gardener can fix it. Applicant will submit proof to Licensing. LPA observed that there are rose bushes in the backyard. Licensee stated that she will supervise the children at all time and plans on putting a gate around it. Applicant also submit proof the right side of the yard is barricaded. There were no bodies of water observed during today's inspection.

LPA discussed the safe sleep regulations with Applicant 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 Applicant of the importance of checking 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.

Applicant does not plan on providing Incidental Medical Services (IMS). IMS policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 publications: Commonly Asked Questions about Child Care Center and the ADA, available at: http://www.ada.gov/childqanda.htm.

Applicant does transport children and has a valid drivers license. Applicant also understands that children cannot be left alone and unattended in parked vehicles.

Applicant does have a valid CPR/1st Aid, which expires on 12/06/2021. Applicant's certificate for Preventive Health and Safety, Lead Poisoning Prevention, and Mandated Reporter training are on file. Applicant completed the Mandated Reporter training on 01/05/2021. Applicant understands that Mandated Reporter training needs to be renewed every 2 years. Applicant's immunization records for measles and pertussis are on file. LPA obtained an updated influenza record during today's inspection.

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SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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: FERNANDEZ DE HARO, GLADIZ
FACILITY NUMBER: 434416747
VISIT DATE: 10/05/2021
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------------------CONTINUATION OF 809 DATED 10/05/2021 PAGE 2------------------------

LPA provided Applicant with a Family Child Care Home packet with updated Licensing forms and reviewed with the Applicant. Department website: www. ccld.ca.gov provided to the Applicant. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, requirements for assistant/substitute, and immunization requirements for staff including the new regulation regarding Pertussis, Measles, and Influenza were discussed with Applicant/Licensee. LPA reminded Applicant/Licensee that fire/emergency drills need to be conducted every 6 months and documented. LPA discussed COVID guidelines with Applicant during today's inspection.

The adults living in the home are Applicant and her daughter. Applicant also has one minor child. All adults have cleared criminal record, child abuse index, and TB clearance, but are not associated to new facility number. Applicant submit LIC 9182 with a valid ID for both herself and her daughter during today's inspection. Applicant was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A updated copy of the LIC 279 and LIC 279B were obtained during today's inspection; along with the LIC 508 and TB test for her daughter.

Applicant stated that she submit the following items:
- proof of control of property
- proof that gap in fence were fixed
- Proof that right side of the yard is barricaded
- updated LIC 999A: Yard

An exit interview was conducted Applicant Gladiz Fernandez de Haro. LPA advised Applicant that a license for a Small Family Child Care Home will be granted and issued upon completion of the following items:
1) fingerprints for Licensee and her daughter are transferred to this facility number
2) Manager's review and approval
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC809 (FAS) - (06/04)
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