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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406575
Report Date: 06/29/2022
Date Signed: 06/29/2022 06:26:08 PM


Document Has Been Signed on 06/29/2022 06:26 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:COSTA, MARIAFACILITY NUMBER:
073406575
ADMINISTRATOR:COSTA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 524-3329
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:14CENSUS: 7DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria CostaTIME COMPLETED:
05:30 PM
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On 06/29/2022 at 3:00 PM, Licensing Program Analyst Christina Watts conducted an unannounced annual inspection for Maria Costa large family child care home. LPA met with licensee, Maria Costa and guided analyst on a tour of the facility. During today's inspection, there were 7 children in care(4 infants and 3 preschool children) and licensee aid/daughter. Facility currently has 8 children enrolled. Facility hours of operations are Monday-Friday from 8:00 am - 5:30 pm.

Family members residing in the home are licensee, licensee adult daughter and adult son, and licensee partner. Licensee's daughter and partner are fingerprint cleared. The licensee son lives in a studio on the property however is currently not fingerprint cleared nor associated to the facility.

This is a one story home which consists of 3 bedrooms, 2 bathrooms, kitchen, dining room, living room ,family room (play room), lower backyard and left side of backyard which includes a deck and a studio bedroom. Facility has stairs outside before you enter the home. The children in use area: playroom (family room) bathroom, son's bedroom, dining room, living room and lower level of backyard. Areas off limits to children include: Master bedroom and bathroom, kitchen, daughter's room, the left side of the yard which includes a deck and a studio bedroom with a bathroom. The LPA toured all areas used by children during this visit.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and central heating system for safety and comfort. There were safe toys, play equipment and materials observed for children. There are no stairs in the home. There is a working telephone in the home. Detergents, poisons, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible in some areas of the home. There are currently no pets in the house.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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: COSTA, MARIA
FACILITY NUMBER: 073406575
VISIT DATE: 06/29/2022
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LPA observed and inspected sleeping equipment for infants. LPA observed a crib and play pen for each infant who is unable to climb out of the playpen or crib. LPA observed one crib has a blanket. LPA reminded licensee she cannot have blankets, toys or pillows inside of the crib or hanging above the crib while child is sleeping. LPA observed that playpen or crib do not hinder the entrance or exit to and from the space they are sleeping in. 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 napping and all infants up to 12 months should be placed on their back for sleeping. Per licensee, there are no weapons or firearms in the home. Licensee has an up to code 3A40BC fire extinguisher and working smoke/carbon monoxide detector on the premises. Observed screened fireplace in family room. Licensee states they conduct fire drills however sent the fire drill log to another county agency.

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.

Children’s records were reviewed to ensure that each child has an Identification and Emergency form. The licensee Pediatric First Aid and CPR certificate expired 03/2022. Licensee is enrolled in course to renew their CPR/First Aid certificate. Licensee daughter has valid CPR/First aid certificate which expires 01/18/2023. Required postings were observed near the entrance. Licensee was unaware of the requirement to maintain Safe Sleep Log for infants naps.

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) Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
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: COSTA, MARIA
FACILITY NUMBER: 073406575
VISIT DATE: 06/29/2022
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On or before March 30, 2018, any person who works in a child care facility shall complete Mandated Reporter training and renew the training every 2 years. LPA reminded licensee to maintain her Mandated Report training and she has to renew every two years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers.

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

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, 1 Type A and 1 Type B violation were observed. Exit interview conducted and report was reviewed with the licensee, Maria Costa. Licensee signed the report acknowledging receipts of documents. A notice of site visit was given and must remain posted for 30 consecutive days.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 06/29/2022 06:26 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: COSTA, MARIA
FACILITY NUMBER: 073406575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(d)(1)
Infant Safe Sleep
The provider shall place infants up to 12 months of age on their backs for sleeping. This requirement shall not apply if the infant has a medical exemption from a licensed physician that allows for an alternative sleep position. The exemption shall be attached to the Individual Infant Sleeping Plan [LIC 9227 (3/20)] and contain the following criteria:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 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: 06/30/2022
Plan of Correction
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Submit statement of how facility will stay in compliance with regulation and how facility will manage infants while sleeping.
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) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 10


Document Has Been Signed on 06/29/2022 06:26 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: COSTA, MARIA
FACILITY NUMBER: 073406575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 record review and interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/06/2022
Plan of Correction
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Submit proof of son's fingerprint clearance form
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) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
LIC809 (FAS) - (06/04)
Page: 5 of 10