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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415945
Report Date: 06/17/2021
Date Signed: 06/18/2021 07:49:14 AM

Document Has Been Signed on 06/18/2021 07:49 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:MONTES, ANAFACILITY NUMBER:
444415945
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Ana MontesTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Elizabeth Berumen met with licensee, Ana Montes for a Required 1 year inspection. LPA explained the nature of today’s visit. Present during today’s visit were Licensee, her 3 childen ages; 12, 6, 4 and 6 day care children (one is an infant, 3 preschoolers and two school age) Licensee states that she is the only adult living in the home with her three children ages 12, 6, and 4. Days and hours of operation are Monday through Friday, 8:00 am to 6:00 pm.

A review of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 06/17/2021 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. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children.
LPA toured the inside and outside of the home. The off limit areas inside the home are the entire upstairs area; which consists of three bedrooms and two bathrooms. Stairs are barricaded. Licensee's two children were in the upstairs area; LPA reminded her that day care children are not allowed in the off limits upstairs area.
The kitchen is off limits and LPA observed a white gate that is used to prevent children from accessing the off limit area. Licensee states there are no firearms/weapons in the home and no pets. LPA observed a 3A40BC fire extinguisher; fire and carbon monoxide detectors were tested and proved to be functioning. Telephone is in working order. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Backyard is fenced.
(report dates 06/17/2021 continues on next page 809c)
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MONTES, ANA
FACILITY NUMBER: 444415945
VISIT DATE: 06/17/2021
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Licensee uses the entire outdoor play yard. The play area is fenced and safe for day care children. LPA reminded licensee that she can only have 8 children according to her license. Children were supervised during the visit and LPA went over substitute options.
Licensee stated that she does currently does no transport children. LPA reminded Licensee that children are not to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.
LPA took a picture of a current roster of the children. LPA observed a fire and disaster drill log; last practiced drill was 02/12/21. LPA reviewed 6 children’s files and observed a copy of the emergency information card (LIC 700) in each file as well as an infant individual sleeping plan (LIC 9227) for the infant in care. LPA observed that the Licensee has completed Mandated Reporter training. LPA reminded Licensee that course is to be renewed every two years. Licensee has Pediatric CPR/1st Aid expiring in April 2022. Licensee has immunization's against pertussis, measles and influenza. Licensee has a TB in her file.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.
Licensee was reminded that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice. LPA discussed the immediate civil penalties for Zero Tolerance of $500 and the Healthy Beverage Act and AB633 requirements for type A violation. Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility. Safe sleep was discussed with the Licensee and Guide to Safe Sleep information was provided to the licensee. Department website: http://ccld.ca.gov provided to Licensee.
Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

An exit interview was conducted with Licensee in Spanish. No deficiencies were cited during today’s inspection
Notice of site visit must remain posted for 30 days.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
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