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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421103
Report Date: 05/11/2022
Date Signed: 05/11/2022 10:52:29 AM


Document Has Been Signed on 05/11/2022 10:52 AM - 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, TILLIEFACILITY NUMBER:
013421103
ADMINISTRATOR:RIVERA, TILLIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 825-8075
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:14CENSUS: 4DATE:
05/11/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Tillie RiveraTIME COMPLETED:
11:10 AM
NARRATIVE
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On 05/11/2022 approximately at 8:50AM, Licensing Program Analyst (LPA) Kelly Phan met with Tillie Rivera for the purpose conducting a plan of correction visit to verify if corrections were made. Present for this inspection was 4 preschool aged children (3 children who are 2 years old and 1 child who is 3 years old). LPA entered the facility and began the inspection of the facility to conduct a health and safety check.

The following deficiency were cited on 4/22/2022 LPA observed and had a record review of the facility file and found that the licensee had an expired CPR and First aid training on 11/02/2021. Type B deficiency was cited. Licensee has not submitted any proof of correction on the POC (Plan of Correction) date of 5/6/2022. She also was made aware that her mandated reporter training has not been completed, to complete a facility roster, and provide LIC 700 to families for two children files.

During the inspection, LPA verified with licensee at 9:15AM that she has not registered for her CPR and First aid renewal training. LPA informs licensee that it is necessary to have a valid CPR and First aid card at all times while children in care are present. LPA also informs licensee that since no corrections were made, a civil penalty of $500.00 today and then $100 per day will be assessed until deficiency is corrected. At 10:00AM, LPA verified, observed, and reviewed facility records that licensee did not have the following a completed mandated reporter training (LPA provided link to licensee), not having a current facility roster, and two children's files were missing LIC 700 (Identification and Emergency information). Type B deficiencies are issued. SEE LIC 809D.

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. Appeal Rights were also given and discussed. An exit interview was conducted with licensee Tillie Rivera





SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly PhanTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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Document Has Been Signed on 05/11/2022 10:52 AM - 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: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2022
Section Cited

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Operation of a Family Child Care Home: 102417(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:
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Based on interview and record review, licensee did not comply with the section stated above as 2 out of 4 children files were missing LIC 700 (Identification and Emergency Information form), which poses a potential health, safety, or personal rights risk to children in care.
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Failure to correct the deficiencies on or before the Plan of Correction (POC) due date will result in a civil penalty of $250.00 then $100.00 per day until corrected
Type B
05/11/2022
Section Cited

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(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 was not met as evidenced by:
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Based on observation, interview, and record review, licensee did not comply with the section stated above as licensee failed to produce a completed mandated reporter training, which poses a potential health, safety, or personal risks to children in care.
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Failure to correct the deficiencies on or before the Plan of Correction (POC) due date will result in a civil penalty of $250.00 then $100.00 per day until corrected
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) 622-2631
LICENSING EVALUATOR NAME: Kelly PhanTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/11/2022 10:52 AM - 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: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2022
Section Cited

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Operation of Family Child Care Home: 102417(8): Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
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Based on observations, interview, and record review, licensee did not comply with the section stated above as licensee failed to provide a copy of her current facility roster, which poses a potential health, safety, or personal rights risk to children in care.
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Failure to correct the deficiencies on or before the Plan of Correction (POC) due date will result in a civil penalty of $250.00 then $100.00 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: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly PhanTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3