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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417737
Report Date: 02/01/2024
Date Signed: 02/01/2024 11:55:20 AM

Document Has Been Signed on 02/01/2024 11:55 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CORDOVA, ANNELFACILITY NUMBER:
434417737
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
02/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Annel CordovaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Teodoro Trujillo conducted an announced pre licensing inspection with Annel Cordova, Applicant. The purpose of today's inspection: address the Application for a Small Family Child Care Home License (Change of Location) that the Applicant submitted to the Department on Nov. 30, 2023. The Applicant is currently licensed at 3861 MAUI DRIVE, San Jose, CA 95111 (Facility #434414472). No children were present in the home during today's inspection. The Applicant, her spouse Cesar Garcia and her adult daughter Damaris Garcia are the adults residing in the home. There is one minor child residing in the home, 15 years old.

Days and hours of operation will be Monday - Friday from 5:00 AM to 5:30PM. Applicant completed her Preventative Health and Safety Child Care Training on 05/22/20221 and a copy of the certification is on file. Applicants CPR and First Aid certifications are current and expire on 05/14/24. Copies of both certifications are on file. Applicant completed the Mandated Reporter Training for Child Care Workers on 05/18/2022, and a copy of the certification is on file. A copy of current TB test, flu vaccinations for the Applicant are on file. Applicant owns the home and a copy of the property tax document verifying control of property are on file. Applicant understands that she cannot care of more than 8 children at any time. Applicant states she have liability insurance with Makel Insurance Company.

LPA toured the indoor and outdoor areas of the home with the Applicant during today's inspection. The Applicant's home is a single story home. LPA observed no stairs during today's inspection. LPA observed no wall heaters in the home. Applicant states that she will operate the day care in the following areas: Living room, and hallway bathroom. Off limit areas inside the home: bedroom 1 with master bathroom, bedroom 2, bedroom 3, kitchen, and attached garage with two rooms that applicant states have not been approved by the city. Off limit outside left and right side yard area and wood storage . On limit outside: Rear back yard.

The home is clean, orderly, (including heating/air conditioning), and ventilation for safety & comfort. There is sufficient toys, supplies, and equipment for the day care children both indoors/outdoors. LPA observed a fully charged fire extinguisher (2A10BC) and working smoke and carbon monoxide detectors, fenced backyard, and no bodies of water. Applicant states that she does not have any weapons/ammunition in the home.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CORDOVA, ANNEL
FACILITY NUMBER: 434417737
VISIT DATE: 02/01/2024
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Applicant states there are is one vaccinated cat in the home. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. Applicant states that poisons are stored in the outside wood storage room. LPA reminded Applicant that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes. Applicant states that she will not administer any medication to the children at this time. Applicant states that a child will be isolated in wicker chair next to kitchen area if necessary due to illness or communicable disease. Applicant has a First Aid kit in the home.

Applicant understands that children's personal rights should not be violated, including no corporal punishment. isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 01/26/24 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions Applicant Annel Judith Cordova 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 requirements of AB 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

LPA provided and reviewed the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LPA also discussed the importance of maintaining records for any person/assistant providing care to the children and children in the home under 10 years of age.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
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: CORDOVA, ANNEL
FACILITY NUMBER: 434417737
VISIT DATE: 02/01/2024
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LPA discussed the safe sleep regulations with licensee Annel Judith Cordova 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 Annel Judith Cordova 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.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:
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: http://www.ada.gov/childqanda.htm

PIN 22-02-CCP - Best Practices Related to the Provision of Incidental Medical Services in Child Care Center and Family Care Homes was provided to Applicant.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. LPA provided the applicant the Department website: www.ccld.ca.gov

Applicant Annel Judith Cordova 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.

Exit interview conducted and report was reviewed with the Applicant, Annel Judith Cordova, and LPA advised her that a small Family Child Care Home License is pending approval by Licensing Program Manage an submission of outside right fence fixed.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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