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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419180
Report Date: 03/16/2022
Date Signed: 03/16/2022 09:00:17 PM


Document Has Been Signed on 03/16/2022 09:00 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, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:PORTILLA, NANCY & ROBERTOFACILITY NUMBER:
013419180
ADMINISTRATOR:PORTILLA, NANCY & ROBERTOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 533-3350
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:14CENSUS: 2DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nancy PortillaTIME COMPLETED:
02:30 PM
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On 03/16/2022 Licensing Program Analysts(LPA) Diana Campos arrived at 10:30am for an unannounced Required 1 year Inspection. LPA met with Licensee Nancy Portilla. Present for this inspection were Licensee's mother who assists with day care and 2 children in care, which consisted of 1 infant and one preschool age child. The home was toured with the Licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 8:30am to 5:30pm.

ON LIMITS: Living room, dining room which has been converted into an activity room/napping area, bathroom on the second level and the backyard patio.
OFF LIMITS: All 3 bedrooms, living room stairs, attached garage, kitchen, and chicken coup area in the back yard. Off limit areas are inaccessible by closed and/or locked doors and visual supervision at all times. Kitchen and laundry area are used by children in care only as walkway to access back yard patio.
The home is two stories, which is neat and clean, with heating and ventilation for safety and comfort. The outdoor play area is the fenced backyard patio, which is free from defects and dangerous conditions. There were ample age appropriate toys that were observed to be safe and in good condition. There is a fully charged 2A10BC fire extinguisher, working telephone, and first aid kit. The home has a fireplace which is blocked to prevent access by children. The home has central heating. Per licensee, there are no firearms in the home. The licensee conducts and documents Fire/Disaster Drills at least twice a year, and the log indicates a drill was conducted 01/24/2022. All required licensing documents are posted and visible for public review.

At 11:00am, 4 children's files were reviewed. The facility roster was reviewed, and a copy obtained. The licensee is in ratio today. Liability Insurance Affidavit is used in place of day care insurance. Safe sleep practices, and new car seat laws were discussed .
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: PORTILLA, NANCY & ROBERTO
FACILITY NUMBER: 013419180
VISIT DATE: 03/16/2022
NARRATIVE
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The licensee was advised of the required mandated reporter training to be completed every two years at www.mandatedreporterca.com. Licensee completed training on 9/16/2020.

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

Licensee 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 licensee 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 licensee 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.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: PORTILLA, NANCY & ROBERTO
FACILITY NUMBER: 013419180
VISIT DATE: 03/16/2022
NARRATIVE
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See 809-D for deficiencies cited today

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

Exit interview conducted and report was reviewed with the licensee Nancy Portilla.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/16/2022 09:00 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, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: PORTILLA, NANCY & ROBERTO
FACILITY NUMBER: 013419180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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 in that licensee did not provide a current cpr/first aid certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2022
Plan of Correction
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Licensee provided proof of registration to renew the cpr/first aid course and certificate during todayh's inspection visit.
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 in at least one out of 6 children in care did not have a signed/completed emergency card/ consent form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2022
Plan of Correction
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Licensee will submit copies of completed and signed forms for child in care by the POC due date.

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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 03/16/2022 09:00 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, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: PORTILLA, NANCY & ROBERTO
FACILITY NUMBER: 013419180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

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 in 1 out of 6 children in care did not have a completed and signed emergency ID card LIC700 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2022
Plan of Correction
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Licensee shall submit a copy of child's emergency ID card to licensing by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7