Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354413617
Report Date: 12/11/2015
Date Signed 12/11/2015 10:23:14 AM

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:LEZAMA, SUSANAFACILITY NUMBER:
354413617
ADMINISTRATOR:LEZAMA, SUSANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 801-0501
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:14CENSUS: 0DATE:
12/11/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Susan LezamaTIME COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analyst (LPA), Maria Mercado conducted an unannounced Random visit to the home today. LPA met with Susana Lezama, Licensee, and explained the nature of today's visit to her. LPA also observed no daycare children in the home during today's visit. Licensee, spouse, two adult sons, daughter-in-law and 1 week old infant reside in the main home. Licensee's sister-in-law and her 3 1/2 yr old and 2 yr old live in the converted garage that is separated from the main home. Licensee understands that all children that reside in the home that are under 10 yrs of age count in the capacity.

Days and hours of operation are Monday - Saturday from 5AM to 6PM. Applicant's CPR and First Aid certifications are current and expires on 01/03/17. Discussed with Susana the new Incidental Medical Services procedures. Ms. Green states she does not have any medication for any of the children. Susana understands she must submit a plan to Licensing if she plans to give Incidental Medical Services in the future. Licensee owns the home. Licensee does have liability insurance for the Family Child Care Home. LPA toured the indoor and outdoor areas during today's visit. LPA observed no stairs in the home. Off limit areas inside the home: 3 bedrooms/1 bathroom, entire upstairs (2 bedrooms, dining room and bathroom that is rented). Off limit areas outside: the right portion of the yard that is properly barricaded with a locked shed. LPA observed a fully charged 3A40BC fire extinguisher, working smoke detector, fenced backyard, and no bodies of water. LPA observed the backyard that is safe for daycare use. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. Licensee states that there are no weapons or bodies of water in the home. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Licensee that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes. Forms of discipline used by Licensee: redirection. Licensee 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 Licensee that fire/disaster drills must be practiced at least once every 6 months or as instructed by the Hollister Fire Department and documented.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 12/11/15):
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Maria MercadoTELEPHONE: (408) 334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2015
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 2


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: LEZAMA, SUSANA
FACILITY NUMBER: 354413617
VISIT DATE: 12/11/2015
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 12/11/15):

A review of staff records on 12/08/15 indicates that all Facility staff or other individuals who require caregiver background checks 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 clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

The Licensee understands the capacity options and understands that she cannot have more than 14 children at any moment with a Large Family Child Care Home without a qualified assistant: MAX. CAP(WHEN THERE IS AN ASSISTANT PRESENT): 12 - NO MORE THAN 4 INFANTS. CAP 14 - NO MORE THAN 3 INFANTS. 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6.
If licensee is alone, the license automatically reverts to a Small Family Child Care Home License: MAX. CAP: 6 - NO MORE THAN 3 INFANTS OR 4 INFANTS ONLY. CAP. 8 - NO MORE THAN 2 INFANTS, 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6.

LPA provided the Department website: www.ccld.ca.gov to Licensee. LPA discussed MyCCL with Licensee.
LPA also discussed "zero tolerance" related regulations with the Licensee and advised her of the assessment of an immediate $150 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $150 per day continues until the violation(s) is/are corrected.

No deficiencies issued during today's visit.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Maria MercadoTELEPHONE: (408) 334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2015
LIC809 (FAS) - (06/04)
Page: 2 of 2