Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409219
Report Date: 11/15/2017
Date Signed 11/15/2017 05:06:16 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:ASCENCIO, RITA & DIAZ. RUBENFACILITY NUMBER:
434409219
ADMINISTRATOR:RITA A. & RUBEN D.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 449-5441
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:14CENSUS: 12DATE:
11/15/2017
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:13TIME COMPLETED:
05:15 PM
NARRATIVE
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LPAs Janet Tse and Deanna Villagrana met with licensee Rita Ascencio for a Plan of Correction inspection. LPAs observed 13 children including two infants with licensee and her assistant in the home at arrival today. Licensee is operating within ratio and capacity today. LPAs toured the indoor and outdoor of the home.

LPAs observed the bouncer is removed from the home. LPAs observed the wall heater screen is installed. Licensee understands that the screen should be secured and stationary during day care hours. Licensee also understands that children will not be able to touch the surface of the wall heater at any times. A current roster of the children was provided to LPA during the inspection. LPAs observed children were provided proper healthful and safe accommodation for napping.

LPAs reviewed children's files. LPAs observed LIC627 Consent for Emergency Medical Treatment and LIC9150 Notification of Additional Children with parents' signatures in each child's file. LPAs observed LIC 9224 Acknowledgement of Receipt of Licensing Report for type A deficiencies cited on 11/03/2017 with parents' signatures in each child's file.

LPAs observed PM286 Immunization records are not maintained or updated in child#1, 2, 3, 5, 7, 9, 10, 13, 14, 15 & 16's files. This is a failure to correct the deficiency cited on 11/03/2017. LPAs observed the storage was not locked. Licensee put a pad lock on the storage door during today's inspection. LPAs observed a diaper rash ointment on the dining table accessible to children. This is a failure to correct the deficiency cited on 11/03/2017. Licensee states she is going to resend the immunization records of herself and her assistants with signatures to LPA by 11/16/2017.

LPA discussed the requirements of AB633 to licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements. Upon receipt, licensee shall post and provide copies of this licensing report to

Facility Evaluation Report dated 11/15/2017 to be continued on next page:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2017
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 4
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: ASCENCIO, RITA & DIAZ. RUBEN
FACILITY NUMBER: 434409219
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2017
Section Cited
CCR
102417(g)(4)
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LPAs observed the storage was not locked. LPAs observed a diaper rash ointment on the dining table accessible to children.

This is a failure to correct the deficiency cited on 11/03/2017
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Licensee put a pad lock on the storage door and removed the ointment during today's inspection.

Civil penalty of failure to correct for $100 per day was assessed.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
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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: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2017
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: ASCENCIO, RITA & DIAZ. RUBEN
FACILITY NUMBER: 434409219
VISIT DATE: 11/15/2017
NARRATIVE
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Facility Evaluation Report dated 11/15/2017 to be continued from previous page:

parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Deficiencies were cited. Notice of site visit was issued and must be posted with type A deficiencies cited for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2017
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: ASCENCIO, RITA & DIAZ. RUBEN
FACILITY NUMBER: 434409219
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2017
Section Cited
CCR
102418(g)
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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
LPAs observed PM286 Immunization records are not maintained or updated in child#1, 2, 3, 5, 7, 9, 10, 13, 14, 15 & 16's files. This is a failure to correct the deficiency cited on 11/03/2017.
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Licensee shall ensure that each child's immunizations are maintained and updated in form PM286. Licensee shall forward copies of the PM286 for child #1, 2, 3, 5, 7, 9, 10, 13, 14, 15 & 16 to LPA by 11/16/2017.
Civil penalty for failure to correct of $100 per day was issued. Civil penalty continues until deficiency is corrected.
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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: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2017
LIC809 (FAS) - (06/04)
Page: 3 of 4