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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415945
Report Date: 10/28/2021
Date Signed: 11/02/2021 12:47:35 PM

Document Has Been Signed on 11/02/2021 12:47 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
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: 8CENSUS: 5DATE:
10/28/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Jessica RuvalcabaTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Berumen met with licensee's assitant, Jessica Ruvalcaba who states Ana Montes is hospitalized. Also present during the inspection were 3 day care children (preschoolers). LPA explained to Jessica the nature of today’s inspection is for an increase in capacity that Licensee requested. 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 10/28/2021 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. LPA heard children upstairs; so upstairs area was inspected. LPA observed Licensee's 3 children (ages 14, 6 and 3).
The kitchen is off limits and LPA observed a white gate that is used to prevent children from accessing the off limit area. Licensee stated on previous inspection on 06/21/21 that there were no weapons in the home. 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 10/28/2021 continues on next page 809c)
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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: 10/28/2021
NARRATIVE
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Licensee uses the entire outdoor play area; the left side of yard and back area. The play area is fenced and safe for day care children. LPA observed a fire and disaster drill log; last practiced drill was on09/21/21. LPA Berumen reviewed Jessica Ruvalcaba's file; Jessica has vaccination against pertussis, measles and has a written statement declining the influenza vaccine. Jessica completed the Mandated Reporter Training on 09/02/2021, LIC 9108 and TB test is on file. Jessica is missing the criminal record statement (LIC 508) and Employee Rights (LIC9052).
LPA reviewed three children files today.
Licensee does transport children in her vehicle. She understands that a child is not to be left alone in the car at any time and she is to have proper child safety seats/belts for each child who requires them.
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.

Fire Marshal approval was granted for a large family day care home license.
An exit interview was conducted with Licensee in Spanish. Deficiencies were cited during today’s inspection (page 809C).

Notice of site visit must remain posted for 30 days.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/02/2021 12:47 PM - It Cannot Be Edited


Created By: Elizabeth Berumen On 10/28/2021 at 03:05 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: MONTES, ANA
FACILITY NUMBER: 444415945

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2021
Section Cited
CCR
102416(a)

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Personnel Requirements
The licensee shall provide each employee with a copy of the Notice of Employee Rights (LIC 9052 (4/88)) form furnished by the Department. A copy of the signed notice form shall be retained in the employee's personnel record.
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LPA provided Assistant, Jessica Ruvalcaba a copy of the LIC 9052; Jessica completed the form and was instructed to keep the top portion of the form for her records. Deficiency cleared during today's inspection.
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This requirement was not met as evidenced by: LPA reviewed employee file; the Employee Rights form (LIC 9053) is not in the file.
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Type B
11/18/2021
Section Cited
CCR102416(c)

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The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement was not met as evidenced by: Upon review of
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CPR & First Aid completion certificate or card- approved by Emergency Medical Services Authority (EMSA) couse shall be taken in person and not online.
Licensee to submit proof of completion by November 18, 2021.
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Assistant's file; LPA learned that the CPR & First Aid course she completed was done online.
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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:Mary Segura
LICENSING EVALUATOR NAME:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021


LIC809 (FAS) - (06/04)
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