Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409256
Report Date: 11/09/2018
Date Signed 11/09/2018 03:28:25 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: 4DATE:
11/09/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Ericka RomeroTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee's assistant, Ericka Romero and discussed with her the reason for today's inspection. Ericka states that Licensee is attending a training. Also present during the inspection were two infants, two preschoolers and Licensee's 12 year old daughter. Days and hours of operation are Monday thru Friday from 7:00 AM to 5:00 PM. Ericka states that Licensee is the only adult living in the home. Licensee's 12 year old daughter lives in the home. A review of staff records on November 8, 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 reviewed Assistant, Ericka's file; she has tuberculosis, criminal record (LIC 508) Acknowledgment to report suspected child abuse (LIC 9108) and employee rights (LIC 9052) on file. She has current CPR & First Aid certification, expiring 02/18/19. Ericka has immunization against pertussis, measles and influenza. Ericka completed the Mandated Reporter Training - AB 1207 Complaint training on 08/24/18.
Licensee has current CPR & First Aid, expiring 01/20/20. Licensee has immunization against pertussis, measles and influenza. LPA reviewed Licensee's file, which contained certificate of completion of Mandated Reporter Training.

LPA inspected the indoor and outdoor areas of the home. Off limit areas are attached garage and two bedrooms. LPA inspected both bathrooms utilized by children. The home is clean and orderly, with heating and ventilation for safety and comfort. LPA observed a 3A40BC fire extinguisher. The home has a working carbon monoxide and smoke detector.

(report dated 11/09/18 continues on following 809C)
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2018
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: FLORES, ROXANA
FACILITY NUMBER: 434409256
VISIT DATE: 11/09/2018
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There is a working telephone in the home. Licensee has a pet dog, LPA reviewed shots. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children are stored where they are inaccessible to children. LPA reviewed current facility roster and reviewed four children files. LPA reviewed fire/disaster drill log, last practiced drill was 08/24/18. Outdoor play area is fenced. The storage shed in the backyard is off limits and locked. The left side yard near the storage shed is off limits. There is a gate preventing children to access the off limit left side yard.

Supervision of children was discussed with Assistant. LPA notes that per title 22 section 102417(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

LPA advises Licensee, Roxanna Flores to go on the website for updates and information. www.ccld.ca.gov

LPA conducted an exit interview in Spanish with Assistant, Ericka.

No Deficiency Cited.

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: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2018
LIC809 (FAS) - (06/04)
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