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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412291
Report Date: 05/24/2022
Date Signed: 05/24/2022 02:44:10 PM


Document Has Been Signed on 05/24/2022 02:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:ZUNIGA, MYRIAM & HENRIQUEZ, MIGUELFACILITY NUMBER:
013412291
ADMINISTRATOR:ZUNIGA, MYRIAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 244-7258
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:14CENSUS: 9DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Myriam Zuniga & Miguel HenriquezTIME COMPLETED:
02:26 PM
NARRATIVE
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On 5/24/2022 at 11:10am Licensing Program Analyst (LPA) Morgan Pringle met with Licensees Myriam Zuniga and Miguel Henriquez for an Unannounced Annual Inspection. Present during the inspection were the Licensees, their criminal record cleared daughter, M. Henriquez, who serves as a helper, one (1) infant, and eight (8) preschool age children. The facility operates 7:00am – 6:00pm, Monday - Friday.

ON LIMITS AREA: Living Room, Children’s Area, Kitchen, Converted Garage, Hallway Bathroom and Backyard
OFF LIMITS AREA: Two (2) Bedrooms, Master Bedroom and Bathroom
ISOLATION AREA: Living room

The facility is a single-story home rented by the Licensees. The inside of the home is observed to be clean with ample age appropriate materials for the children. All toxins, cleaning products, personal medications, and hazardous materials were observed to be in inaccessible areas. Licensees has stated that there are no firearms one (1) cat in the home.

The home has one (1) fully charged 3A40BC fire extinguisher in the converted garage. One working smoke/carbon monoxide detector is in the garage and another carbon monoxide detector is in the hallway. The fireplace in the living room is screened and not in use making it inaccessible to the children in care. The home is equipped with plenty of windows for proper ventilation and central heat. LPA did not observe any harmful bodies of water in or around the home.


Continued on LIC809-C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ZUNIGA, MYRIAM & HENRIQUEZ, MIGUEL
FACILITY NUMBER: 013412291
VISIT DATE: 05/24/2022
NARRATIVE
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The Licensees Health and Safety training has been completed. Licensees Pediatric CPR and First Aid training is complete and expires in 6/2022 and 7/2022. Licensees Mandated Reporter training's have not been renewed and are expired. Fire/disaster drill log has not been completed as well. All required forms are posted and visible for public view in the converted garage. LPA obtained the children’s files and facility roster. Facility roster is complete. Children’s files are not complete.

Deficiencies cited today (See LIC809-D):
· HSC 1596.8662(b)(1) - Expired Mandated Reporter Training certificates
· CCR 102417(g)(9)(A) - Incomplete Fire/disaster drill log
· CCR 102427(g)(7) - Infant in care from another facility with no file & School Age child
enrolled with missing file
· CCR 102418(g) - Two children missing Immunization records

Technical Violations (not deficiencies, See LIC9102TV):
· Infant in care is missing sleep log

Licensees was reminded that California Law requires Licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensees that all forms can be downloaded at www.ccld.ca.gov. Licensees was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.

Licensees was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The Licensees is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.


Continued on LIC809-C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ZUNIGA, MYRIAM & HENRIQUEZ, MIGUEL
FACILITY NUMBER: 013412291
VISIT DATE: 05/24/2022
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensees was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Licensees and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensees of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

A notice of site visit was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with Licensees Myriam Zuniga and Miguel Henriquez.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/24/2022 02:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: ZUNIGA, MYRIAM & HENRIQUEZ, MIGUEL
FACILITY NUMBER: 013412291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review and interview the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensees will complete a fire/disaster drill by POC date. Licensees will document the drill and send proof od documentation to LPA Pringle.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensees will complete Mandated Reporter training by POC date. Licensee will submit certificate of completeion to LPA Pringle.

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: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 05/24/2022 02:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: ZUNIGA, MYRIAM & HENRIQUEZ, MIGUEL
FACILITY NUMBER: 013412291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensee will ensure to obtain completed file for both children who are missing a file at the facility. Licensees will send proof of completed file to LPA Pringle by POC date.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensees will obtain immunization records for all three children enrolled in care. Licensees will send proof of immunization record to LPA Pringle.

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: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6