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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415945
Report Date: 06/15/2022
Date Signed: 06/21/2022 04:52:36 PM

Document Has Been Signed on 06/21/2022 04:52 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:ANA MONTESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 254-7878
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Ana MontesTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPA's) Elizabeth Berumen and Araceli Almaraz, met with Licensees, Ana Montes for an unannounced Required - 1 Year Inspection. Also present in the home were five day-care children including two (2) infants and 2 preschoolers and one school age. Licensee's assistant, Belinda Jeronimo Jeronimo Licensee's three children (ages 13, 8 and 5) and two nephews (11 and 9). LPA was granted access to the home by the Licensees and toured both indoor and outdoor areas during the inspection. LPA observed all required posted materials. Days and hours of operation for the facility are Monday – Friday, 8:00 AM- 6:00 PM. There are no active waivers or exceptions for this facility. Licensee states she is the only adult living in the home. Licensee has three children ages; 13, 8, 5 that live in the home.

Licensee 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. Licensee requested to remove Jesus Morales Rodriguez from her day care.

LPA observed a current children's roster. Fire/disaster drill was conducted on May 4, 2022. LPA observed a fully charged 3A40BC fire extinguisher and functioning smoke and carbon monoxide detectors. Ana states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. Ana states that there are no weapons or firearms in the home.


Continuation on next pages:
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 06/15/2022
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Indoor licensed areas of the facility were inspected by LPA today and observed to be clean, orderly, and safe for the day care children. Off limit areas in the home: are entire upstairs (3 bedrooms and two bathrooms), laundry closet and kitchen. LPA observed barricaded stairs. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as table, chairs, and shelves are in good condition and safe for children. The home has a working telephone which is (831) 254-7878. The backyard is fenced. There were no bodies of water observed.

LPA discussed the safe sleep regulations with Ana 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 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

Five children’s files were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), and Immunization Records.

Licensees has immunization's in measles, pertussis, and flu. Ana's Mandated Reporter Training expires on 02/07/22. Ana has current CPR & First Aid, expiring 04/04/2024. Licensee completed the mandated reporter training on 02/07/22. Licensee's assistant (Belinda Jeronimo) does not have the mandated reporter training

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SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
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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: 06/15/2022
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To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process


Exit interview conducted and report was reviewed with the Licensee, Ana Montes.

As a result of todays inspection, deficiency was cited on the following pages:

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/21/2022 04:52 PM - It Cannot Be Edited


Created By: Elizabeth Berumen On 06/15/2022 at 12:59 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: 06/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above; Licensee's assistant does not have the mandated reporter training available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2022
Plan of Correction
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Licensee agrees to submit a copy of the Mandated Reporter Training for her assistant (Belinda Jeronimo Jeronimo) by plan of correction date of 06/22/22.
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:Mary Segura
LICENSING EVALUATOR NAME:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022


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