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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422288
Report Date: 02/21/2023
Date Signed: 02/21/2023 10:55:45 AM


Document Has Been Signed on 02/21/2023 10:55 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, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:CID, ADELITAFACILITY NUMBER:
013422288
ADMINISTRATOR:CID, ADELITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 549-6368
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:14CENSUS: 4DATE:
02/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Adelita CidTIME COMPLETED:
11:30 AM
NARRATIVE
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On 02/21/2023 at 9:15 AM Licensing Program Analyst (LPA), A. Curry arrived at the home and conducted an unannounced random inspection. LPA was greeted by Licensee's assistant, Martha Castillo, who granted inspection authority to tour the facility. Martha stated the licensee was at a doctor's appointment. Licensee, Adelita Cid, arrived to the home shortly after. Also present for the inspection were 4 children in care, Licensee states there are currently 4 children enrolled. Children’s files were reviewed.

The LPA entered the day care area through the side of the home. The children use the front play room, bedroom, and backyard. The off-limits areas will be inaccessible by closed and/or locked doors and visual supervision. The isolation area is in the bedroom. The LPA toured all areas used by children.



Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There were no fireplaces or open face heaters accessible to children. There were safe toys, play equipment, and materials observed for children. There were no stairs accessible to children. There is a working telephone in the home. All poisons, cleaning solutions, medications, and other items that pose a danger to children are inaccessible during this visit. The licensee does understand that poison must be in a locked cabinet/drawer or placed out of reach of children. The home is equipped with a fully charged 2A10BC fire extinguisher and working dual smoke alarm and carbon monoxide detector. Licensee stated there are no firearms on the premises. There are no pools, spas, hot tubs, fishponds or similar bodies of water. Licensee has current CPR and First Aid training which expires on March 10, 2023 respectively. Licensee's assistant could not provide a valid CPR/ First Aid Certificate, completion of Preventative Health Training, or valid Mandated Reporter certificate during today's visit (See 809D). Licensee is aware that if assistant is alone with day care children, then she must have all valid certifications required by LIcensing in her file.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CID, ADELITA
FACILITY NUMBER: 013422288
VISIT DATE: 02/21/2023
NARRATIVE
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LPA observed and inspected sleeping equipment for infants. All equipment meets the US Consumer Product Safety Commission safety standards. Mattresses were observed to be firm and covered with a fitted sheet that is appropriate to the mattress size. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months of age should be placed on their back for sleeping (See 809D). LPA observed an 8 month old infant sleeping on stomach.. Licensee's assistant stated the child rolls onto stomach while sleeping. Child did not have the LIC 9227 form in file. Licensee is aware that all infants up to 12 months of age should have the LIC 9227 form in file.

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.

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.

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.

Exit interview conducted, appeal rights were given, and report was reviewed with the licensee Adelita Cid

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/21/2023 10:55 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, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: CID, ADELITA
FACILITY NUMBER: 013422288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
102416.1(a)(6)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (6) Documentation of completion of training on preventative health practices as required by Section 102416(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by ensuring assistant who is left alone with day care children have a valid CPR/First Aid card, Preventative Health Training Certifications, and Mandated Reporter Training in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2023
Plan of Correction
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By 03/21/2023 Licensee will submit proof of valid certifications for CPR/First aid Training, Preventative Health Training, and Mandated Reporter Training.
Request Denied
Type B
Section Cited
CCR
102425(d)
Infant Safe Sleep
The provider shall place infants up to 12 months of age on their backs for sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above by ensuring all infants up to 12 months of age are placed on their backs for sleeping and each infant up to 12 months of age have the LIC 9227 Individual Sleeping Plan form in file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2023
Plan of Correction
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Licensee's assistant immediately placed child on back. Licensee's assistant stated the child is placed on back but rolls over while sleeping. Child did not have the LIC 9227 form in file. By 03/07/2023 Licensee will submit a completed LIC 9227 form that indicates child rolls over in sleep.
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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5