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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070209044
Report Date: 04/14/2022
Date Signed: 04/15/2022 03:30:20 PM


Document Has Been Signed on 04/15/2022 03:30 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, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:CLARK, GUADALUPE & JUDSONFACILITY NUMBER:
070209044
ADMINISTRATOR:CLARK, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 937-6152
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:12CENSUS: 6DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Teresa Ramirez (helper)/Patrick Clark (son)TIME COMPLETED:
02:30 PM
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On 4/14/22 at 9:45 am Licensing Program Analysts (LPAs) Monica Mathur and Christina Watts conducted an unannounced Annual Inspection at Guadalupe and Judson Clark's Family Day Care Home. LPAs were greeted by Assistant, Teresa Ramirez and a second adult who stated she is a volunteer, Ljubica Chase. Teresa stated both Licensees, Guadalupe and Judson were out of town and they were taking care of 6 children today (4 infants, 2 preschool age). LPAs explained the purpose of today’s inspection and were granted permission to enter the facility. LPAs also spoke with both licensees over the phone. Adults residing in the home are Licensee and Co-Licensee. File review shows volunteer Ljubica Chase has been providing supervision and care to children for 1 day during licensees absence, but does not have background check clearances. She is not related to any day care child. Type A citation and Civil Penalty of $100 (for 1 day) is assessed.
At 10:00 am LPAs toured the INDOOR spaces of the home with Assistant, Teresa
In Use Areas: Living room, Family room, Dining area, Kitchen, Child Bedroom, Bathroom between Master Bedroom and Child Bedroom, Half Bathroom in Laundry Room, Laundry Room Off Limit Areas: Master Bedroom, Third Bedroom, Shop. During today's inspection, LPAs observed both off limit bedrooms are being used for nap time. Teresa stated they have been using them for naps. Observed play yards had loose objects, stuffed animals inside but no children were sleeping in them during inspection. Licensees were advised off limit areas are not approved and cannot be used for day care.
LPA observed sufficient materials, toys, and play equipment for the day care children in the home. Children were engaged in various activities under the supervision of the Assistant and Volunteer. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Furniture and equipment, such as cribs, mats, feeding chairs, and tables were age appropriate and in good condition. There were no baby walkers or bouncers observed on the premises during today’s inspection. The home is sanitary, orderly, and safe for the day care children. LPA did not observe any wall heaters in the home. There is screened fireplace and no stairs inside the home. The Licensee has a working telephone in the home.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044
VISIT DATE: 04/14/2022
NARRATIVE
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LPA observed a fully charged 3A40BC fire extinguisher and working smoke / carbon monoxide detectors. There is a pet cat and no firearms in the home. LPA reviewed a current Children Roster, Emergency Disaster Plan LIC610A. There was no documentation for last fire/disaster drill. All required postings - Parent Rights Poster PUB394, Facility License, Emergency Preparedness LIC9148 were observed available near the entrance. Day care home appeared to be free of flies, other insects, and rodents during today’s inspection.

At 11:00 am OUTDOOR space was inspected. A small portion of the backyard right outside the Family room sliding door is enclosed with child gates and used by children. Rest of the yard is off limit. The outdoor space and play equipment were observed to be maintained in safe condition and free of hazards. The yard was fenced and there were no bodies of water.

FILE REVIEW: At 11:15 am Children, Assistant files were reviewed. 4 child files did not contain Immunizations information. An enrolled infant under age 1 did not have a file and there was no documentation for Individual Safe Sleep Plan LIC9227. There was no documentation for infants Sleep Log. Assistant's Mandated Reporter Training was expired and Volunteer did not have any documentation for measles, pertussis, TB, CPR or Mandated Reporter. Licensee's certifications for CPR/First Aid and Mandated Reporter Training are also not current.

At about 11:30 am Licensees' son Patrick Clark showed up at the facility and helped Teresa with paperwork. He printed out a Live Scan Form for Ljubica Chase and informed her to get live scan done by end of today. Patrick stated he does not live in the home, resides nearby but visits often.
Supervision of children was discussed with the Patrick Clark, reminder that Licensees must be present in the home during 80% of the operating hours of the day care. In their absence they must ensure at least one supervising adult caring for children has current CPR/First Aid, and access to facility files/paperwork per Licensing requirements.

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
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
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: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044
VISIT DATE: 04/14/2022
NARRATIVE
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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.

In the areas that were evaluated, regulatory violations were observed. Citations are issued on 809-D pages of this report. Technical advisories were given.
LPA Monica Mathur informed Assistant Teresa and Licensee's son Patrick Clark that this report dated 4/14/22 with 1 Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Mathur informed the Assistant Teresa and Licensee's son Patrick Clark to provide a copy of this licensing report dated 4/14/22 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Exit interview conducted and report was reviewed with Licensee's son Patrick Clark.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 27 of 27
Document Has Been Signed on 04/15/2022 03:30 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, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation) (interview) (record review)], the licensee did not comply with the section cited above. Volunteer LJUBICA CHASE has been volunteering for 1 day, providing supervision/care to day care children; is not related to any child in day care and is not fingerprinted or associated to license; which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty of $100 for 1 day is assessed.
POC Due Date: 04/15/2022
Plan of Correction
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By end of 4/15/22 Licensees shall ensure LJUBICA CHASE has completed Live Scan formalities and get assocaited to license. Licensees to submit proof of live scan completion to Licensing by end of 4/15/22.
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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 23 of 27


Document Has Been Signed on 04/15/2022 03:30 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, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(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 is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. S1 and S2 do not have current certification in Mandated Reporter Training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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By end of 5/12/22, Licensee shall ensure all adults caring for children have current mandated reporter training, remewal every 2 years and submit completion of training to Licensing by POC due date.
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
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. S1 and S2 who were caring for children today did not have current CPR First Aid which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Licensees to ensure they have current CPR First Aid certification and in their absence, at lease 1 supervising adult had CPR certification. Submit proof of current certifiation by end of POC due date.

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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 26 of 27


Document Has Been Signed on 04/15/2022 03:30 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, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
102416.3(a)(6)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above - 2 out of 3 bedrooms are supposed to be off limit. Per inspection today, LPA observed all 3 bedrooms are being used for naps. There were crib and play yards observed in each room. Assistant S1 stated all bedrooms are used for napping children. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2022
Plan of Correction
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Effective immediately both bedroom that were supposed to be off limit, cannot be used for nap or day care. Licensees to submit a written statement verifying they will not use these rooms prior to Licensing's approval.
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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 25 of 27