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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070213499
Report Date: 05/04/2022
Date Signed: 05/04/2022 01:10:29 PM


Document Has Been Signed on 05/04/2022 01:10 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:ELIZALDE, MIRTHA & CARLOSFACILITY NUMBER:
070213499
ADMINISTRATOR:ELIZALDE, MIRTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 285-6161
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:12CENSUS: 7DATE:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mirtha ElizaldeTIME COMPLETED:
01:30 PM
NARRATIVE
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On 5/4/22 at 9:15 am Licensing Program Analysts (LPAs) Monica Mathur and Christina Watts conducted an unannounced Annual Inspection at Mirtha Elizalde's Family Day Care Home. LPAs met with Licensee, Mirtha and explained the purpose of today’s inspection. LPA was granted permission to enter the facility. Days and hours of operation are Monday - Friday from 7 am - 5 pm. Present in the home were Licensee, 1 Helper and 7 day care children (6 infants, 1 preschool age). Facility is out of compliance with required ratios today. Licensee states 2 infants present today are attending on trial basis and not enrolled yet.

LPA toured the INDOOR spaces of the home
In Use Areas: Florida Room, Family Room, Kitchen, Dining area, Bathroom in Hallway
Off Limit Areas: All 3 bedrooms, Office, Garage, Living room, Master bathroom
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 Licensee and Helper 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, exersaucers, jumpers or bouncers observed on the premise 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 a screened fireplace in family room. No stairs inside the home. The Licensee has a working telephone in the home.

LPA observed a fully charged 2A10BC fire extinguisher and working smoke/carbon monoxide detectors. The Licensee states that she does not have any weapons or pets in the home. LPA reviewed a current Children Roster, Emergency Disaster Plan LIC610A. Licensee states she has not conducted or documented fire/disaster drill. All required postings - Parent Rights Poster PUB394, Facility License were observed posted on a wall. The Licensee states that she does not transport children.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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 11


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: ELIZALDE, MIRTHA & CARLOS
FACILITY NUMBER: 070213499
VISIT DATE: 05/04/2022
NARRATIVE
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OUTDOOR space was inspected.
In Use Areas: Left side yard gate leads to entrance into day care. It is also kids outdoor play yard.
Off Limit Areas: Pool, Spa area (gated/fenced and off limit to children)
The outdoor space and play equipment were observed to be maintained in safe condition and free of hazards. The yard was fenced.

FILE REVIEW: Children, Licensee files were reviewed. Helper's file is not maintained. Licensee states she is unaware of the requirement to maintain employee files. Licensee and Helper do not have current Mandated Reporter Training. Licensee states she and Helper took the CPR First Aid training but did not have proof of certification. Stated she has to access it online with her son's help.

Around 11 am a parent came to pick up an infant, bringing census to 5 infants, 1 preschooler,

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during 80% of the operating hours of the day care and ensure that the children are supervised at all times.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 11
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: ELIZALDE, MIRTHA & CARLOS
FACILITY NUMBER: 070213499
VISIT DATE: 05/04/2022
NARRATIVE
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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.
It is noted that Licensee was provided Safe Sleep Regulation Concepts document during previous annual inspection of 12/12/19.

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 assistance and advisory notes were issued.

LPA Monica Mathur informed Licensee, Mirtha that this report dated 5/4/22 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 Licensee, Mirtha to provide a copy of this licensing report dated 5/4/22 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 the licensee Mirtha Elizalde.

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

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 05/04/2022 01:10 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: ELIZALDE, MIRTHA & CARLOS
FACILITY NUMBER: 070213499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Observed during inspection, there were 6 infants and 1 preschooler present. Licensee stated 2 infants were attending on a trial basis and not enrolled yet. During inspection, 1 infant was picked up by parent, bringing total to 5 infants, 1 preschooler. Facility is out of ratio today. Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
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By POC Due Date 5/5/22 Licensee agreed to send a written plan and schedule of attendance on how she will bring facility into compliance with ratio requirements of Large Family Home, with no more than 4 infants present at any time.
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: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 4 of 11


Document Has Been Signed on 05/04/2022 01:10 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: ELIZALDE, MIRTHA & CARLOS
FACILITY NUMBER: 070213499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Licensee states she does not conduct fire drills and was aware of the requirement. However, noted that annual inspection report of 12/12/19 stated facility conducted and documented drills. Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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By POC Due Date 5/11/22 Licensee shall conduct and document a fire disaster drill on a Log. She agreed to submit CCLD a copy of Log as proof.
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: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 5 of 11