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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416851
Report Date: 05/15/2019
Date Signed: 05/15/2019 11:19:54 AM

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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:VERGARA, ANGELAFACILITY NUMBER:
013416851
ADMINISTRATOR:VERGARA, ANGELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 477-9129
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:14CENSUS: 13DATE:
05/15/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Angela VergaraTIME COMPLETED:
11:30 AM
NARRATIVE
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On 05/15/19, Licensing Program Analysts Briana Plumboy and DIane Perez, met with licensee Angela Vergara for an UNANNOUNCED RANDOM INSPECTION. Present for this visit was 1 infant and 12 preschool age children in care, as well as licensees fingerprint clear adult son Christopher Vergara and licensees husband Ronaldo Padilla , and licensees teenage daughter who is also assisting with the child care. The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 7:30am until 6:00pm.

The home is single story. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the sun room, family room, dining room, and hallway bathroom. The OFF LIMIT AREAS are the two bedrooms, the garage, and the master bedroom/bathroom which will be inaccessible by closed and/or locked doors and visual supervision. The ISOLATION AREA will be the family room. The BACKYARD play area is fenced. There are toys and learning supplies/equipment. There are no pools, hot tubs or any other bodies of water present during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible to children during today's inspection.

The home has a fully charged fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The licensee CPR and First Aid certificate is current and expires 09/16/19. The licensee's mandated reporter training is complete and she received a certification of completion on 05/06/18. The licensee, assistant Estelita Vergara, and son Christopher Vergara are in compliance with the immunization law. The fireplace is barricaded to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 03/04/19.

The licensee is not ratio today. REQUIRED forms are posted and visible for public review. See 809-C and 809-D for continuance
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: 510-286-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: VERGARA, ANGELA
FACILITY NUMBER: 013416851
VISIT DATE: 05/15/2019
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

LPA Plumboy provided a copy of Safe Sleep Regulation Concept to the licensee

The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility.

Effective August 1, 2003 California Law requires Family Child Care Home 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 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.

The licensee was also reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list



See 809-D for deficiency cited today. Appeal Rights Provided. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019
LIC809 (FAS) - (06/04)
Page: 2 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: VERGARA, ANGELA
FACILITY NUMBER: 013416851
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2019
Section Cited
CCR
102416.5(a)
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Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement was not met as evidenced by:
Based on observation and a physical census conducted, there was 1 infant and 12 preschool age children present at the facility.
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The licensee Angela Vergara will watch the Capacity/Ratio video which can be found on ccld.ca.gov will submit a plan of action to the department by 05/17/19.
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During the inspection, the environment appeared to be controlled. The facility was out of ratio when LPAs arrived which poses an potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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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: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019
LIC809 (FAS) - (06/04)
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