Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444412309
Report Date: 05/28/2015 12:00:00 AM
Date Signed 05/28/2015 03:47:28 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:DELGADILLO, JACQUELINEFACILITY NUMBER:
444412309
ADMINISTRATOR:DELGADILLO, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 724-4648
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:14CENSUS: 3DATE:
05/28/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Jacqueline DelgadilloTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Darryl Liu conducted an unannounced random visit to the home today. LPA met with Jacqueline Delgadillo, Licensee, and explained the nature of today's visit to her. LPA observed three day care children (2 pre-school, 1 school-age) in the home during today's visit. Days and hours of operation are Monday - Friday from 7:00 A.M - 8:00 P.M. The adults in the home today are the Licensee. LPA toured the indoor and outdoor areas of the home during today's visit.

INDOORS: Off limit areas inside the home: upstairs and garage.. The home is clean & orderly for children. LPA Liu saw upon arrival stairs un-barricaded stairs near the front of the house which is required by regulations.

LPA observed a fully charged 2A10BC fire extinguisher, a working smoke detector, and no bodies of water. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and similar items are stored inaccessible to children. The Licensee has a working telephone in the home.


OUTDOORS: Off limit areas outside the home: fenced side yard. There is bird feces all on the ground and LPA Liu asked the licensee to clean it up. The off limit side yard fence is completely broken.

Paperwork: LPA Liu reviewed current children files, and out of date fire drill log, and up to date First Aid/CPR Card. LPA Liu requested the licensee to send an updated roster to licensing.

A review of staff records on 5/28/15 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.

TYPE "B" VIOLATIONS WERE CITED DURING THIS VISIT.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Darryl LiuTELEPHONE: 408-334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2015
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 3


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: DELGADILLO, JACQUELINE
FACILITY NUMBER: 444412309
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2015
Section Cited
102417(g)(3)
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102417(g)(3) Operation of a Family Child Care Home. Where children are less than five years old are in care, stairs shall be fenced or barricaded.

Stairs were unbarricaded at the facility. There were children under the age of five in the day care.
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Licensee put the barricades up for the stairs.

DEFICIENCY CLEARED.
Type B
06/29/2015
Section Cited
102417(g)(8)
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102417(g)(8) Operation of a Family Child Care Home. All homes shall have a current roster of the children.

Licensee did not have a completed children's roster.
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Licensee will mail a copy of a completed children's roster by 06/29/15.
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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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Darryl LiuTELEPHONE: 408-334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2015
LIC809 (FAS) - (06/04)
Page: 3 of 3


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: DELGADILLO, JACQUELINE
FACILITY NUMBER: 444412309
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2015
Section Cited
102417(g)
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102417(g) Operation of a Family Child Care Home. The home shall be free from defects or conditions which might endanger a child.

The fence for the off-limit side yard is completely broken.
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Licensee will submit a proof to licensing the fence was fixed by 06/29/15.
Type B
05/28/2015
Section Cited
102416.2(b)
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102416.2(b) Reporting Requirements. The licensee shall report to the Department
any of the events as specified in Health and Safety Code Section 1597.467(b)(1)(A)
through (b)(1)(C) that occur during the operation of the family child care home.

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Licensee understands the requirement to report any incidents.

Licensing Program Analyst Darryl Liu received a unusual incident report from the incident which occurred in Jan/Feb.

DEFICIENCY CLEARED.
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Licensee did not report an incident which occurred in January/February.
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Type B
06/29/2015
Section Cited
102417(g)(9)(A)
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102417(g)(9)(A)(1) Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill.

Licensee did not have an up to date fire drill log.

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Licensee will submit a copy of her fire drill log by 06/29/15
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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Darryl LiuTELEPHONE: 408-334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2015
LIC809 (FAS) - (06/04)
Page: 2 of 3