Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409256
Report Date: 11/04/2016
Date Signed 11/04/2016 02:24:43 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:FLORES, ROXANAFACILITY NUMBER:
434409256
ADMINISTRATOR:ROXANA FLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 225-1561
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:14CENSUS: 11DATE:
11/04/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Roxana FloresTIME COMPLETED:
02:40 PM
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2) Licensing Program Analyst (LPA), Elizabeth Berumen, met with Licensee, Roxana Flores, for an annual random visit. Also present in the home was licensee's helper and 11 day care children (4 infants and 7 pre-school children). Licensee is the only adult living in the home with her 9 year old daughter.

Days and hours of operation are Monday thru Friday from 5:30 AM to 5:30 PM. Licensee has current CPR and First Aid certification with an expiration date of October 2017. LPA toured the home both inside and out. The home is clean, orderly and safe for the children. LPA observed a fully charged 3A40BC fire extinguisher, working smoke and carbon monoxide detector and fenced backyard. No bodies of water were observed. Off limit areas include 2 bedrooms, garage and storage shed in the backyard. Off limit areas outside the home are fenced off side of the yard and locked storage shed. Licensee has a pet dog with current vaccinations. Licensee states there are no weapons in the home. Medicines, cleaning compounds, poisons, and other similar items are stored inaccessible to the children. All required postings are posted. Disaster drill log and roster were reviewed. The home has a working telephone which is (408) 225-1561.

This facility provides Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA was provided: US Department of Justice (USDOJ) 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

(report continues on 809C)
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2016
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: FLORES, ROXANA
FACILITY NUMBER: 434409256
VISIT DATE: 11/04/2016
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LPA informed Roxana of the new immunization requirement for her and adults who work with children; measles, pertussis and influenza. Roxana has vaccinations for herself and helper, Erika Romero.

A review of staff records on November 5, 2016 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

No deficiency cited today.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2016
LIC809 (FAS) - (06/04)
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