Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354413617
Report Date: 03/22/2018
Date Signed 03/22/2018 01:46:57 PM

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: 2DATE:
03/22/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Susana LezamaTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an unannounced annual random inspection to the home today. LPA met with Susana Lezama, Licensee, and explained the nature of today's inspection to her. Present today was Licensee's son Ricardo and licensee's daughter in law Maria. Days and hours of operation are Monday to Saturday from 6:00 AM to 6:00 PM. The adults that reside in the home are the Licensee, her sons Francisco, Ricardo and Carlos, licensee's daughter in law Maria and licensee's spouse Jose. There were 2 children in care, they are Licensee's grandchildren and the mother of the children was also present. Other than the licensee's grandchildren there were no other children in care. Licensee stated she is working with the migrant program Gokids and has not received children yet. Licensee's and Licensee's spouse certifications for CPR and First Aid card are current and will expire on 01/07/2019.
.LPA toured the indoor and outdoor areas of the home during today's inspection. LPA reviewed the Child Care Facility Roster during today's inspection and it is current. Licensee has documented a fire drill during the last six months. Last fire drill was documented on 03/10/2018.
The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Off limit areas inside are: 3 bedrooms, one bathroom and the laundry room. There is also a second floor which only access is outside the home by the right side yard. LPA observed there are no stairs inside the home. Off limits areas outside: Right side of the back yard. The back yard is fenced and the licensee uses a section as playground whenever the weather allows it. LPA observed a fully charged 2A10BC fire extinguisher and at least one working smoke detector. LPA observed the home has a working carbon monoxide detector and no bodies of water. LPA observed there are not wall heaters and a barricaded fireplace. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children. LPA discussed Incidental Medical Services (IMS) with the Licensee.
LPA explained to the Licensee of the immunization requirement for pertussis, measles, and flu vaccines for all Licensees and staff that work directly with the children (SB792). Licensee believes she has immunization but was unable to present proof of immunization for pertussis, measles and influenza for herself and for her spouse and helper Jose. Licensee understands that this is a deficiency to the health and safety regulations.

Report dated 03/22/2018 continues in page 2.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2018
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: LEZAMA, SUSANA
FACILITY NUMBER: 354413617
VISIT DATE: 03/22/2018
NARRATIVE
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Report dated 03/22/2018 continues from page 1.

A review of staff records on 03/05/2018 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 also 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.
Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time, and a helper must be present. Licensee understands that in absence of a helper her license becomes capacity and ratio of 8 children only (small FCCH license) The Licensee states that she transports children via vehicle and that she understands that children cannot be left in parked vehicles unattended at any time. Licensee uses redirection and communication with children as a form of discipline.
Department website: www.ccld.ca.gov provided to Licensee.
LPA discussed the requirements of AB 633 whenever a Type A deficiency is cited. LPA also discussed "zero tolerance" related regulations with the Licensee and advised her of the assessment of an immediate $500 civil penalty in addition to $100 per day civil penalty for any violation of a "zero tolerance" related regulation, and ongoing civil penalty of $100 per day continues until the violation(s) is corrected.
LPA prior to the conclusion of today's inspection advised the Licensee of the required "mandated reporter" training that all Licensees will be required to complete starting January 1, 2018. Licensee has already taken the training on 3/17/2018. LPA referred the Licensee to the Department website: www.ccld.ca.gov for additional information on the online training.

One deficiency type B was cited during today's inspection. Appeal rights was printed and given to Licensee. Exit interview was conducted with licensee in Spanish.

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

DATE: 03/22/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2018
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: LEZAMA, SUSANA
FACILITY NUMBER: 354413617
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2018
Section Cited
HSC
1597.622(a)(1)
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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Licensee shall obtain proof of immunization for herself and for her spouse Jose and will submit a copy to the Licensing Department by April 5, 2018.
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Licensee believes she has immunization but was unable to present proof of immunization for pertussis, measles and influenza for herself and for her spouse and helper Jose. Licensee understands this is a deficiency to the health and safety regulations.
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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 SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2018
LIC809 (FAS) - (06/04)
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