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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421853
Report Date: 02/09/2022
Date Signed: 02/09/2022 11:52:18 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:MONTOYA, ROBERTFACILITY NUMBER:
013421853
ADMINISTRATOR:MONTOYA, ROBERTFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 377-8148
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:14CENSUS: 8DATE:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:16 AM
MET WITH:Robert MontoyaTIME COMPLETED:
11:55 AM
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On February 9, 2022 at approximately 8:16am Licensing Program Analyst (LPA) Russ Haderer met with licensee Robert Montoya for the purpose of conducting an unannounced annual inspection for health and safety. Upon arrival, present were the licensee and 3 children in care (2 infants and 1 toddler). During the inspection, 2 assistants arrived and 5 additional children (2 infants and 3 toddlers). The facility is in ratio today. The hours of operation are Monday-Friday, 7:30am to 6:00pm.

The facility is a single-story home with 3 bedrooms and 1 bathroom, a living room fireplace covered with a wooden gate to prevent access), a small infant area (formerly a dining room), kitchen, attached 2-car garage front, side and back yards. The home s neat and clean with heating and ventilation for safety and comfort.



The outdoor play area is large and includes a large play structure on the left side of the yard that is anchored to the ground, and many other activity areas, which are free from defects and dangerous conditions. The outdoor play area has an inside small fence to keep the northern and patio areas of the house off limits to children. There are ample age appropriate toys/activities inside and outside that were observed to be safe and in good condition. The areas used for childcare include the front living room and dining areas, the rear two rooms, which are the art and nature studios, hallway bathroom, and the backyard.

On-limit-areas include: The living room, the infant sleeping area, the house bathroom, two back bedrooms (nature and art studio) side yard and backyard.

Off-limit-areas include: The kitchen, the first room on the left side of the hallway, the attached two car garage and the northern area of the backyard and the patio and the attached 2-car garage. Off limit areas are inaccessible by closed and/or locked doors and visual supervision. Toxins, medicines, and hazardous items were inaccessible during today's inspection.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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 5
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: MONTOYA, ROBERT
FACILITY NUMBER: 013421853
VISIT DATE: 02/09/2022
NARRATIVE
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There is a fully charged 2A10BC fire extinguisher located just inside the garage, The facility has working (tested and functioning) smoke and carbon monoxide detectors. 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 11-17-2021. All required licensing documents are posted and visible for public review.

At 10:00am, children's files were reviewed and found to be complete. The facility roster was reviewed, and a copy obtained. All files were organized and complete. At 10:45 staff files were reviewed. Proof of MMR vaccinations missing for licensee and one helper. See LIC809D.

The licensee’s Pediatric CPR/First Aid certificate is current and expires 1/7/2024, helpers CPR 1st Aid certificates also current. Mandated reporter training was completed (licensee on 6/14/2021, helpers done June 2021).

LPA reminded the licensee of the following: Mandated Reporter training is to be renewed every two years, CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.

The licensee owns the property and is currently switching liability insurance company.

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

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.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: MONTOYA, ROBERT
FACILITY NUMBER: 013421853
VISIT DATE: 02/09/2022
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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/inspection-process.

LPA discussed the safe sleep regulations with licensee [or facility representative] 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 [facility representative] 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.

There was one Type B deficiency issued today for missing proof of MMR vaccinations for licensee and one helper. This report will remain on file for 3 years.

A review of operating safely during the Covid-19 pandemic (RAST) was conducted.



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

Exit interview conducted and report was reviewed with the licensee Robert Montoya.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: MONTOYA, ROBERT
FACILITY NUMBER: 013421853
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

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 2 individuals (did not have proof of MMR vaccinations in the personnel file of the licensee and one assistant) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2022
Plan of Correction
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Licensee and Assistant will obtain copies of their MMR vaccinations to keep in their personnel file and also forward copies to LPA for internal Licensee file.
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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
LIC809 (FAS) - (06/04)
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