013421103-4-22-2022-52-CC-KPHN-CDQUHE-20220422153549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013421103
Report Date: 04/22/2022
Date Signed: 04/22/2022 03:36:00 PM

Document Has Been Signed on 04/22/2022 03:36 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:	RIVERA, TILLIE		FACILITY NUMBER:	013421103
ADMINISTRATOR:	RIVERA, TILLIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 825-8075
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	14	CENSUS: 3	DATE:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Tillie Rivera		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/22/2022 approximately at 1:10PM, Licensing Program Analyst (LPA) Kelly Phan arrived at for an unannounced required inspection, and met with Licensee Tillie Rivera. Present for this inspection was three preschool aged children. Also residing in the home is the licensee's fingerprinted associated husband and their two adult daughters. The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 6:00am to 6:00pm. ON LIMITS: bedroom #4 across from bathroom #1, bathroom #1, living room, kitchen, and backyard OFF LIMITS: garage, bedroom #1, bedroom #2, and bedroom #3, outdoor shed, and right side yard. Off limit areas are inaccessible by closed and/or locked doors, and visual supervision. The home is single story, which is neat and clean, with heating and ventilation for safety and comfort. There were ample age appropriate toys that were observed to be safe and in good condition. Toxins and medicines were inaccessible during today's inspection. There were a fully charged 3A40BC fire extinguisher, working carbon monoxide, smoke detectors, and telephone. Per licensee there is not a fireplace at the facility. Per licensee, there are no firearms or any bodies of water in the home. The licensee does have a dog. The licensee conducts and documents fire drill log indicates a drill was conducted 12/03/20. All required licensing documents are posted and visible for public review. At 1:45PM, LPA toured the backyard and observed a swing set and other toys that are in good condition. LPA also toured the bedroom used by day care children and observed loose blankets inside the play pens; licensee were able to remove blankets immediately. LPA also observed disposable razor heads in the bottom of bathroom sink. LPA suggests to licensee to move it, and licensee was able to remove it to an inaccessible area today on 4/22/2022. SEE LIC 809 C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: RIVERA, TILLIE	FACILITY NUMBER: 013421103
	VISIT DATE: 04/22/2022

NARRATIVE

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At 2:30pm, 3 children's files were reviewed and two children's file were missing LIC 700 (Identification and emergency form). The facility roster was reviewed, and LPA suggests to licensee to send an updated copy to LPA by 4/29/2022. The licensee is in ratio today. Licensee has proof of the required immunization. Licensee does not have mandated reporter training; LPA suggests licensee to send completion of mandated reporter training by 4/29/2022. CPR and First Aid training are also valid as of 11/02/2021. LPA recommends licensee to send proof of renew of CPR and First aid training approved by EMSA by 5/6/2022.

There was a Type B deficiency were cited for today's inspection:

TYPE B: At 2:30PM, LPA reviewed and observed that licensee's CPR and First aid training are expired as of 11/01/2021. Licensee is also aware that her trainings were expired upon reviewing her documents. LPA suggests licensee to send proof of renewal of training. SEE LIC 809D for reference.

Appeal rights and a notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00. Exit interview conducted and report was reviewed with licensee Rivera

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 te 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.

SEE LIC 809 C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/22/2022 03:36 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: RIVERA, TILLIE	FACILITY NUMBER: 013421103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2022

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
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section above as licensee fail to renew both CPR and First aid training that expired on 11/01/2021, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/06/2022
	Plan of Correction
1 2 3 4	Licensee would send proof of completion to LPA by Licensee would also register for training

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: RIVERA, TILLIE	FACILITY NUMBER: 013421103
	VISIT DATE: 04/22/2022

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. This facility does not provides IMS to children in care. 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.”

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.

Licensee was reminded that California Law requires licensed Child Care Centers 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 electronic mail. LPA informed the Facility Representative that all forms can be downloaded at www.ccld.ca.gov and encouraged the Facility Representative to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

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.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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