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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421853
Report Date: 01/25/2023
Date Signed: 01/25/2023 12:03:13 PM


Document Has Been Signed on 01/25/2023 12:03 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:MONTOYA, ROBERTFACILITY NUMBER:
013421853
ADMINISTRATOR:MONTOYA, ROBERTFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 377-8148
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:14CENSUS: 10DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Robert MontoyaTIME COMPLETED:
12:05 PM
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On January 25, 2023 at approximately 8:40am 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 7 children in care (3 infants and seven toddlers). During the inspection, 1 assistant arrived and 3 additional children. 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 (with a 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 is 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 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 od 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.

There is a fully charged 2A10BC fire extinguisher located inside the garage next to the small garage door, 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, however the log is missing to confirm a drill was conducted every six months – see LIC809D for deficiency. All required licensing documents are posted and visible for public review.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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: MONTOYA, ROBERT
FACILITY NUMBER: 013421853
VISIT DATE: 01/25/2023
NARRATIVE
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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. Sleeping logs for infants were in use and available for review. The licensee owns the property and is currently looking for a new liability insurance company. Parents of children have not signed the LIC282 acknowledgement form – see LIC809D for deficiency. Staff records were reviewed. Proof of MMR vaccinations missing for new assistant – see LIC809D for deficiency.

The licensee’s and helper’s Pediatric CPR/First Aid certificate is current and expires 1/7/2024. Mandated reporter training was completed (licensee on 6/14/2021, helpers done June 2021). LPA reminded the licensee of the following: Mandated Reporter and CPR/1st Aid training is to be renewed every two years, Baby bouncers & drop-down cribs are not allowed at the day-care facility.

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.

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

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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: 01/25/2023
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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.

There were 3 Type B deficiencies issued today: Proof of MMR vaccinations for assistant; Missing LIC282 forms acknowledging no liability insurance signed by parents; Disaster drill log missing to confirm drills are conducted at least once every six months.

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: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/25/2023 12:03 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: MONTOYA, ROBERT
FACILITY NUMBER: 013421853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child 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 that no disaster drill log was available to confirm drills have been completed very six months which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2023
Plan of Correction
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Licensee will conduct a disaster drill and continue conducting them at least once every six months.

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: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 01/25/2023 12:03 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: MONTOYA, ROBERT
FACILITY NUMBER: 013421853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023

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 that the new assistant did not have proof of measles vaccination or immunity which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2023
Plan of Correction
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Licensee to provide proof of measles vaccination or immunity for assistant and going forward ensure these records are always collected an held in personnel files.
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

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 the licensee's former liability insurance coverage has expired. Licensee looking for new carrier but at this time has no coverage and parents have not signed acknowledgement form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
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Licensee to collect signed licensing form LIC282 Acknowledgement of no Liability Insurance from all parents of children in care.
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: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
LIC809 (FAS) - (06/04)
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