Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409221
Report Date: 01/10/2018
Date Signed 01/10/2018 01:40:02 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:LARA, GABRIELAFACILITY NUMBER:
434409221
ADMINISTRATOR:GABRIELA LARAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 843-8720
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 8DATE:
01/10/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Gabriela LaraTIME COMPLETED:
01:45 PM
NARRATIVE
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(3) Licensing Program Analyst (LPA) Elizabeth Berumen conducted an unannounced random visit to the home today. LPA met with Licensee, Gabriela Lara and explained the nature of today's visit to her. LPA also observed assistant, Dora Gutierrez and 8 day care children; 3 infants and 5 preschoolers. Days and hours of operation are Monday to Friday from 6:00 AM to 6:00 PM. Gabriela states that her husband and herself are the only adults living in the home and her 3 children (6, 14, 16). Licensee's certifications for CPR and First Aid are current and expire, May 2018.
LPA inspected he indoor and outdoor areas of the home during today's visit. LPA reviewed a Child Care Facility Roster; children birth dates are missing on the roster. LPA reviewed a fire disaster drill, last drill practiced on December 13, 2017. LPA reviewed eight children's files and observed current and updated immunization records and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A). Licensee states she has two working telephone numbers. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean and orderly for the children. LPA did not observe any wall heaters inside the home. Fire place in the living room is barricaded. Off limit areas in the home are entire upstairs (4 bedrooms & two bathrooms), laundry room downstairs and garage. LPA observed barricaded stairs. Gabriela states that her backyard is off limits. She is using the front yard as outdoor play area. Gabriela understands that 100 percent supervision is required when children are out in an unfenced area. Gabriela states her phone (408) 840-9021 and (408) 510-4820. She will submit an updated LIC 279 with that information and also update the adults who live in the home.
LPA observed a fully charged 3A40BC fire extinguisher. working smoke and carbon monoxide detector. LPA observed that the backyard is fenced and there is a pool that meets title 22 requirements. The Licensee states that she does not have any weapons. Gabriela has a pet dog. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children.

(REPORT DATED 01/10/18 CONTINUES ON FOLLOWING PAGE)
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2018
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: LARA, GABRIELA
FACILITY NUMBER: 434409221
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2018
Section Cited
CCR
102423(a)(2)
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Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations, furnishing and equipment.

LPA observed a 17 month old child restrained and asleep in a bouncer chair.
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LPA asked Gabriela to remove child from bouncer. She is to immediately cease napping or restraining infant children in bouncers or simialr items. Gabriela to send LPA a written plan explaining how she will nap infants in crib or mats that are designed for sleeping.
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Upon receipt, licensee shall post and provide copies of this licensing report to 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.
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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: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2018
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: LARA, GABRIELA
FACILITY NUMBER: 434409221
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2018
Section Cited
CCR
102417
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Operation of a Family Child Care Home.

All homes shall have a current roster of the children.
Licensee's roster is not complete. Children's birthdates.
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Gabriela states she will complete her roster by 01/24/18 and submit a copy to LPA by plan of correction date.
Type B
01/24/2018
Section Cited
HSC
1597.622(a)(1)
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EMPLOYEES OR VOLUNTEERS AT FAMILY DAY CARE HOME; IMMUNIZATION REQUIREMENTS; RECORDS - 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.
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Licensee to obtain immunization records for Measles, pertussis and influenza for herself and submit a copy to the department by the Plan of Correction (POC) date of June 30, 2017.
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Gabriela and assistant Dora Gutierrez do not have documentation indicating they have immunizations against pertussis, measles and influenza.
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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: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2018
LIC809 (FAS) - (06/04)
Page: 3 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: LARA, GABRIELA
FACILITY NUMBER: 434409221
VISIT DATE: 01/10/2018
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE ( REPORT DATED 01/10/18

A review of staff records on January 9, 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.

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 with a qualified assistant present. When she is alone her license reverts back to a small license. The Licensee states that she does not transport children via vehicle; however, she understands that children cannot be left in parked vehicles unattended at any time.


LPA advised Ms. Lara of the required "mandated reporter" training that all staff will be required to complete starting January 1, 2018. LPA referred her to the Department website: www.ccld.ca.gov for additional information on the online training.
New failure to correct civil penalties were discussed with Ms. Lara.

LPA advised that licensing forms and all other information can be found at: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing

LPA conducted an exit interview with the Licensee prior to the conclusion of today's visit. This visit was conducted in Spanish.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS ALONG WITH A COPY OF THIS REPORT.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2018
LIC809 (FAS) - (06/04)
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