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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415239
Report Date: 03/05/2024
Date Signed: 03/05/2024 11:28:10 AM

Document Has Been Signed on 03/05/2024 11:28 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:CHAVEZ, CARMENFACILITY NUMBER:
444415239
ADMINISTRATOR:CHAVEZ, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 345-7762
CITY:FREEDOMSTATE: CAZIP CODE:
95019
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
03/05/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Carmen ChavezTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo met with licensee Carmen Chavez for an unannounced annual inspection and explained the nature of today’s visit to her. Present was today one preschool age child. Present was Licensee's helper Ilda. The adults living in the home are Licensee, her husband J. Guadalupe, her adult children Hector, Dorian, and Carmen, and her sister Ilda. Days and hours of operation are Monday through Friday, 6:00 am to 6:00 PM.

LPA toured the inside and outside of the home. LPA observed no fireplace and no wall heaters. LPA observed barricaded stairs. Off limits indoor: Second floor, kitchen, and the attached garage. There are no bodies of water or firearms/weapons in the home. LPA observed a 3A40BC fire extinguisher that was last serviced on 4/27/23. Smoke detector and Carbon Monoxide detectors are operable.
Home is clean and orderly with heating and ventilation for safety and comfort. LPA observed sufficient materials, toys, and play equipment for the children in care. Each child has safe healthful, and comfortable accommodations, furnishings, and equipment. Telephone is in working order. Medicines, poisons and cleaning supplies are inaccessible to the children. Backyard is fenced. Off limits outdoor: Garage.
LPA reminded licensee that she can only have 14 children according to her license, and a helper must be present. Licensee understands that without a helper her capacity is reduced to a small license maximum 8. Licensee understands that ratio (age of the children) must be observed for both sizes.
Children were supervised on the visit.
LPA observed in the helper file proof of TB negative test, SB 792 requirements, AB1207 proof of training on 8/15/22 and pediatric CPR card expiring on 8/05/24.
Licensee stated that she does not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and they must follow all CA rules pertaining to the transportation of children.

Report dated 3//05/24 continues on page 2.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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: CHAVEZ, CARMEN
FACILITY NUMBER: 444415239
VISIT DATE: 03/05/2024
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Report dated 3/05/24 continues from page 1.

LPA obtained a copy of the children's roster and observed the fire and disaster drill was documented on 2/14/24. LPA reviewed five children's files and observed that parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification and emergency information forms are in each file. Licensee has completed the Mandated Reporter training on 2/27/23 Licensee has a Pediatric CPR/ first Aid expiring on 2/05/25.

A review of staff records on 3/01/24 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
Licensee Carmen Chavez 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.
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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 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 publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Report dated 3/05/24 continues on page 3.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
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: CHAVEZ, CARMEN
FACILITY NUMBER: 444415239
VISIT DATE: 03/05/2024
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Report dated 3/05/24 continues from page 2.

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 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.

During the exit interview, the LICENSEE Carmen Chavez confirmed that there are no Registered Sex Offenders living in the facility.



Exit interview conducted and report was reviewed with the licensee Carmen Chavez.

No deficiencies were cited today.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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