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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407708
Report Date: 05/10/2023
Date Signed: 05/10/2023 05:55:28 PM


Document Has Been Signed on 05/10/2023 05:55 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:LOPEZ, GUADALUPEFACILITY NUMBER:
073407708
ADMINISTRATOR:LOPEZ, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 516-7645
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:14CENSUS: 2DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Guadalupe LopezTIME COMPLETED:
06:00 PM
NARRATIVE
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On 05/10/2023 at 2:10 PM, Licensing Program Analyst (LPA) Christina Watts conducted an unannounced annual inspection for Guadalupe Lopez's large family child care home. LPA met with licensee and guided analyst on a tour of the facility. During today's inspection, there were 2 children in care and 6 children enrolled. Also present during inspection was licensee's adult foster child, licensee's 4 foster children ages 10 years old (2 children) 11 year old and 12 year old and licensee's 13 year old grandchild. Family members residing in the home are licensee, licensee husband, licensee's adult foster child, licensee's adult grandchild and licensee's 6 foster children ages 13, 12, 11, 11, 10, and 10 years old. Facility hours of operations are Monday -Friday from 6:00 AM - 6:00 PM.

Upon LPA's arrival to facility, LPA observed licensee's adult foster child caring for two daycare children (1 infant and 1 school age child) without CRIMINAL RECORD CLEARANCE or Pediatric CPR/First Aid training while the licensee was not present in the facility. 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. Licensee and adults in the home have current Criminal Record Clearance. LPA also reminded licensee that an aide/assistant is REQIUIRED to have Pediatric/CPR First Aid training if licensee is not present in the facility.

This is a two story home which consists of 5 bedrooms, 4 bathrooms, kitchen, dining room, living room, family room, laundry room, attached garage, backyard with a locked shed.


The children on limits areas: Living room, family room, kitchen/dining room, first floor bathroom and backyard.
Areas off limits include: Entire second floor, laundry room and attached garage.
The LPA toured all areas used by children during this visit. *CON'T ON PAGE 2*
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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 9


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: LOPEZ, GUADALUPE
FACILITY NUMBER: 073407708
VISIT DATE: 05/10/2023
NARRATIVE
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*PAGE 2*

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 stairs in the home that are made inaccessible for children in care. There is a working telephone in the home. Detergents, poisons, cleaning compounds, medications, and other items which can pose a danger to children are made inaccessible in the home.

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. LPA observed a screened fireplace in the family room. Licensee last conducted fire drill 04/2023. Licensee stated there are no pets in the home.


LPA inspected the backyard and observed a fully fenced and safe backyard for children in care. LPA also observed age appropriate toys for children to play with. LPA did not observed any bodies of water in the backyard. Facility provides transportation for children, but understands that children cannot be left alone, unattended in parked vehicles. LPA reminded licensee when outside of facility, 100% supervision of children in care is required.

Children’s records were reviewed to ensure that each child has an Identification and Emergency form. The licensee Pediatric First Aid and CPR certificate will expire in 04/2024. Required postings were observed near in the living room and family room.

LPA reminded licensee day care needs to be operated within the limitations and capacity of a Large Family Child Care Home with regards to ratios and that Licensee has to be present in the day care for 80% of the operation hours. *


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. *CON'T ON PAGE 3*

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

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 9
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: LOPEZ, GUADALUPE
FACILITY NUMBER: 073407708
VISIT DATE: 05/10/2023
NARRATIVE
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*PAGE 3*

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.

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. Website provided: https://www.mandatedreporterca.com/training/child-care-providers. Licensee has provided Mandated Reporter certificate and the certificate will expire 06/2024.


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

LPA Christina Watts informed licensee, Guadalupe Lopez that this report dated 05/10/2023 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. A civil penalty of $500 has been assessed today.

Also, LPA Watts informed the licensee to provide a copy of this licensing report dated 05/10/2023 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.

*CON'T ON PAGE 4*

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

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: LOPEZ, GUADALUPE
FACILITY NUMBER: 073407708
VISIT DATE: 05/10/2023
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*PAGE 4*

LPA Christina Watts informed Guadalupe Lopez that this report dated 05/10/2023 documents a Type B citation. Type B citation(s) are a potential risk(s) to the health, safety, or personal rights of children in care.

*SEE LIC 809D FOR DEFICIENCIES*

Exit interview conducted and report was reviewed with the licensee, Guapadule Lopez. 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: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 05/10/2023 05:55 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: LOPEZ, GUADALUPE
FACILITY NUMBER: 073407708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above when LPA observed licensee's adult child caring for children without a fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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By 05/11/2023, Licensee is required to start the process for fingerprint clearance for adult foster child. Licensee must submit proof to licensing. After starting the process, licensee is required to obtain clearance for adult foster child.
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: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 05/10/2023 05:55 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: LOPEZ, GUADALUPE
FACILITY NUMBER: 073407708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 and interview, the licensee did not comply with the section cited above when licensee's adult foster child was caring for children without Pediatric CPR/First Aid training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2023
Plan of Correction
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Licensee is to enroll adult foster child into CRP/First Aid training and send completed certificate to licensing.
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: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 6 of 9