Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444412309
Report Date: 08/09/2017
Date Signed 08/09/2017 12:03:11 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:
08/09/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jacqueline DelgadilloTIME COMPLETED:
12:15 PM
NARRATIVE
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Analyst Behbood met with licensee Jacqueline Delgadillo. Present also were 3 children 2 of which day care children. Living in the facility are licensee , her husband and 3 of her minor children. Days and hours of operation are Monday through-Friday, from 7 AM to 5:30 PM. All adults living in the home have criminal record clearance as well as child abuse index. They all meet TB test requirement.
LPA and licensee toured both inside and outside of the home. There are no bodies of water present. Licensee states that there are no firearms/weapons in the home. Medicines, poisons and cleaning supplies are inaccessible to the children. There is a fully charged fire extinguisher, operational smoke and carbon monoxide detector. Home appears clean, has proper heating, lighting and ventilation for safety and comfort. LPA observed safe and sufficient toys, play equipment, materials and supplies for the day-care. Telephone is in working order. Licensee understands smoking is prohibited. Licensee identified the following off limit area inside the home: Kitchen, garage and the entire second floor. Off limit area outside: the two side yards. The playground is fenced with adequate toys. Gates block the off limit areas. Supervision of children was discussed with the licensee and she understands that she must be present in the home 80 percent of the time during day care hours and ensure that the children are supervised at all times. Licensee has current CPR and First Aid that expires on 05/2019. Licensee stated she is up to date with all her required immunization, she was advised to get a copy of her immunization record for her file. She has an up to date children's roster. The fire drills are documented. Children were supervised during the visit. Licensee states she doesn't transport children for now. She understands children may never to be left in parked vehicles. She understand car seat law.

Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

Please see next page for citation under Title 22

SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2017
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 2


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: 08/09/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2017
Section Cited
102417(g)(1)
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Operation of Family Child Care Home : Fire extinguishers and smoke detectors shall meet State Fire Marshal standards.
Fire extingushir is not the right size.
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Proof of purchase must be received no later than 08/11/2017.
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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: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2017
LIC809 (FAS) - (06/04)
Page: 2 of 2