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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417281
Report Date: 11/19/2024
Date Signed: 11/22/2024 02:08:21 PM

Document Has Been Signed on 11/22/2024 02:08 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:ABESAMIS, MONICAFACILITY NUMBER:
434417281
ADMINISTRATOR/
DIRECTOR:		ABESAMIS, MONICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 391-0159
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
11/19/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:licensee, Monica AbesamisTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA's), Anna Morales and Shine Yu conducted an unannounced Annual inspection today and met with licensee. LPA's arrived the facility at 12:10pm. LPA's observed required posting including Facility License, Parent Rights (PUB394). LPA's also observed Emergency Disaster Plan (LIC610A). Licensee stated her husband (the only adult beside herself) and two sons, 9 yrs old and 4 yrs old, residing at the facility.

Facility tour was conducted, and records were reviewed for staff and children. There are 10 children, two of them is under 2 years old. Licensee does not have a current mandated reporting training (expired June, 2024). Licensee pediatric CPR and first aid expires Apr. 2026. Children records were complete with immunization records, parents right, and consent form.



LPA's toured indoor and outdoor areas. LPA's observed only one play yard in the living room, LPA advised the licensee the cover sheet for mat should be tightly fitted, no loose object in the crib. Licensee stated she will order additional crib immediately. LPA observed smoke/carbon monoxide detector in the hallway right out side of bathroom. The last fire drill date 11/19/24. LPA advised the Licensee to conduct fire Disaster drills once every six months and document it.

There is a Fire extinguisher in kitchen area, LPA advise the licensee to keep the receipt with extinguisher for inspection reference. The bathroom is clean and in good working condition. LPA advised the license to lock the under sink cabin door. The house is free of odor and pests. Children have access to living room, bath room, and back yard. Off limits areas inside the home, is kitchen, and the three bedrooms. There are age-appropriate toys for children. Licensee stated there is no firearm in the facility. The fireplace is proper barricaded in the facility. There is no body of water observed outside of play yard. The outdoor play area is enclosed with appropriate fence and safe for children.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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: ABESAMIS, MONICA
FACILITY NUMBER: 434417281
VISIT DATE: 11/19/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

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.
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.
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 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.

As a result of today's inspection, three type B and two Technical violations were issued during today's inspection. During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. A notice of site visit was given and must remain posted for 30 days. Appeal right were given. Exit interview conducted and report was reviewed with the licensee.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/22/2024 02:08 PM - It Cannot Be Edited


Created By: Syhshyan Yu On 11/19/2024 at 02:29 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: ABESAMIS, MONICA
FACILITY NUMBER: 434417281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above LPA's observed only one portable crib/crib for two infants(C1 and C2),which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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LIcensee ordered a play yard/portable crib during this inspection and informed LPA's that it will arrive on 11/20/24, in the morning. Licensee will submit photos of the playyard/portable crib, which is to include the fitted sheets on the mattress to CCL by the POC date.
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview,record review, the licensee did not comply with the section cited above in LPA's did not observe LIC9227 for C1 and for C2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee will submit a copy of LIC9227 for C1 and C2 to CCL by the POC date.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/22/2024 02:08 PM - It Cannot Be Edited


Created By: Syhshyan Yu On 11/19/2024 at 02:29 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: ABESAMIS, MONICA
FACILITY NUMBER: 434417281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
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: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview,record review, the licensee did not comply with the section cited above in Licensee/staff are not documenting the 15 min checks for C1 and C2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee will submit a PLAN to ensure that she is complying with Safe Sleep Regulations, and the 15 minutes checks for C1 and C2.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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