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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
073408754
Report Date:
10/17/2023
Date Signed:
10/17/2023 02:53:03 PM
Document Has Been Signed on
10/17/2023 02:53 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:
BYMASTER, MIRNA
FACILITY NUMBER:
073408754
ADMINISTRATOR:
MIRNA BYMASTER
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(510) 225-8564
CITY:
SAN PABLO
STATE:
CA
ZIP CODE:
94806
CAPACITY:
14
CENSUS:
6
DATE:
10/17/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:06 AM
MET WITH:
TIME COMPLETED:
03:02 PM
NARRATIVE
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On October 17, 2023 at 11:06am Licensing Program Analyst (LPA) Indira Loza met with Licensee Mirna Bymaster for the purpose of conducting an unannounced 1-year annual inspection. Present during today's inspection were the Licensee, the Licensee's two minor children staying home from school, a fingerprint cleared Assistant - Elizabeth Decherd, two infants, and four preschool age children. Operating days and times are Monday - Friday 8am-4pm.
The house is a single story family home consisting of three bedrooms and two bathrooms, a garage, and large backyard, living room, dining room, and kitchen.
On Limit Areas
- are the living room, dining room, kitchen, and hallway bathroom.
Off Limit Areas
- all three bedrooms, and garage, bathroom in the licensee's bedroom, and backyard is temporarily off limits due to construction, which will be inaccessible by closed and/or locked doors, safety gates and visual supervision.
ISOLATION AREA
- Depends on what activities are taking place but the child stays near the group while waiting to be picked up
The home is neat and clean with heating and ventilation for safety and comfort. There is a 3A40BC fire extinguisher and a working combined smoke detector and carbon monoxide detector in the living room. Per the Licensee there are no firearms in the home. The children bring their food from home. LPA observed plenty of toys and activities for the children. The Licensee usually uses the backyard for outdoor play but it is currently under construction. Until the backyard is fully constructed, the Licensee states she takes the children out for walks for outdoor play. There are no pools, hot tubs or any other bodies of water on the premises during today's inspection.
LPA reviewed 4 children files and one staff file. The Licensee could not locate two children files and one
**********************************Report Continues on LIC 809-C*******************************
SUPERVISOR'S NAME:
Mayla Mendoza
TELEPHONE:
(510) 292-9724
LICENSING EVALUATOR NAME:
Indira Loza
TELEPHONE:
510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE:
10/17/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2023
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
12
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:
BYMASTER, MIRNA
FACILITY NUMBER:
073408754
VISIT DATE:
10/17/2023
NARRATIVE
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staff file. The Licensee and her assistant had a current CPR certificate expiring in 2025. The Licensee and her assistant did not have a current Mandated Reporter Certificate. The Licensee had an Affidavit Regarding Liability Insurance for Family Child Care Homes (LIC282) which was in the children's files whose were available for review except for two children. One infant in care is under 12 months, and they did not have an Individual Infant Sleeping Plan (LIC9227). Both infants did not have a sleep log. LPA observed an infant being swaddled during nap. LPA observed an expired Epi-Pen at the facility.
The Licensee provides Incidental Medical Services (IMS). LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02. When any IMS 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
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed on Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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.
**********************************Report Continues on LIC809-C******************************
SUPERVISOR'S NAME:
Mayla Mendoza
TELEPHONE:
(510) 292-9724
LICENSING EVALUATOR NAME:
Indira Loza
TELEPHONE:
510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE:
10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2023
LIC809
(FAS) - (06/04)
Page:
12
of
12
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:
BYMASTER, MIRNA
FACILITY NUMBER:
073408754
VISIT DATE:
10/17/2023
NARRATIVE
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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
is a Plan for the inspection and its tools and methods, please visit the Program website at
www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process
During the Exit Interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
There were one Type A and 9 Type B deficiencies cited during today's visit. See LIC809-D for citations.
Exit interview conducted and report was reviewed with Licensee Mirna Bymaster.
Report and Appeal Rights were provided.
A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME:
Mayla Mendoza
TELEPHONE:
(510) 292-9724
LICENSING EVALUATOR NAME:
Indira Loza
TELEPHONE:
510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE:
10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2023
LIC809
(FAS) - (06/04)
Page:
2
of
12
Document Has Been Signed on
10/17/2023 02:53 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:
BYMASTER, MIRNA
FACILITY NUMBER:
073408754
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/17/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 Epi-pen at the facility was expired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/18/2023
Plan of Correction
1
2
3
4
The Licensee shall watch the CDSS video on Personal Rights, send the LPA a statement of what was learned, and have the parent send an unexpired Epi-Pen to the facility no later than October 18, 2023.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Mayla Mendoza
TELEPHONE:
(510) 292-9724
LICENSING EVALUATOR NAME:
Indira Loza
TELEPHONE:
510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE:
10/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2023
LIC809
(FAS) - (06/04)
Page:
3
of
12
Document Has Been Signed on
10/17/2023 02:53 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:
BYMASTER, MIRNA
FACILITY NUMBER:
073408754
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/17/2023
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the last drill conducted was on May 2, 2022 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
1
2
3
4
The LIcensee shall conduct a fire/disaster drill, update the drill log, and send a picture to the LPA no later than November 14, 2023.
Type B
Section Cited
CCR
102425(f)
Infant Safe Sleep
An infant shall not be swaddled while in care.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in an infant was swaddled which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
1
2
3
4
The Licensee shall review the provided Safe Sleep regulations and list what was learned from them, this must be emailed to the LPA no later than November 14, 2023.
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:
Mayla Mendoza
TELEPHONE:
(510) 292-9724
LICENSING EVALUATOR NAME:
Indira Loza
TELEPHONE:
510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE:
10/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2023
LIC809
(FAS) - (06/04)
Page:
4
of
12
Document Has Been Signed on
10/17/2023 02:53 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:
BYMASTER, MIRNA
FACILITY NUMBER:
073408754
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/17/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in 2 out of 2 infants did not have a sleep log with the time of each 15 minute check, and documenting the condition of the child which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
1
2
3
4
The LIcensee shall send the LPA a copy of an Infant sleep log documenting the following, the child's name, time of each check and whether the child was hot, red, sweaty, fussy, or normal during each check. This shall be sent to the LPA no later than November 14, 2023.
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 of 2 staff did not have a current Mandated Reporter Certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
1
2
3
4
The Licensee shall email the LPA a copy of a current Mandated Reporter certificate for herself and her assistant by November 14, 2023.
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:
Mayla Mendoza
TELEPHONE:
(510) 292-9724
LICENSING EVALUATOR NAME:
Indira Loza
TELEPHONE:
510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE:
10/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2023
LIC809
(FAS) - (06/04)
Page:
5
of
12
Document Has Been Signed on
10/17/2023 02:53 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:
BYMASTER, MIRNA
FACILITY NUMBER:
073408754
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/17/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(d)
Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of two staff did not have their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
1
2
3
4
The Licensee shall send the LPA a copy of Elizabeth Decherd's file by November 14, 2023.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 6 children did not have the ID card on hand which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
1
2
3
4
The Licensee shall send the Identification and Emergency Form (LIC700) by November 14, 2023.
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:
Mayla Mendoza
TELEPHONE:
(510) 292-9724
LICENSING EVALUATOR NAME:
Indira Loza
TELEPHONE:
510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE:
10/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2023
LIC809
(FAS) - (06/04)
Page:
6
of
12
Document Has Been Signed on
10/17/2023 02:53 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:
BYMASTER, MIRNA
FACILITY NUMBER:
073408754
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/17/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out 6 children did not have the Parent's Rights which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
1
2
3
4
The LIcensee shall send the LPA a copy of the Parent's Rights by November 14, 2023.
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:
Mayla Mendoza
TELEPHONE:
(510) 292-9724
LICENSING EVALUATOR NAME:
Indira Loza
TELEPHONE:
510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE:
10/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2023
LIC809
(FAS) - (06/04)
Page:
7
of
12
Document Has Been Signed on
10/17/2023 02:53 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:
BYMASTER, MIRNA
FACILITY NUMBER:
073408754
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/17/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in 2 out of 2 children did nto have the Affidavit Regarding Liability Insurance in their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out 6 children did not have the Affidavit Regarding Liability Insurance which poses a potential health, safety or personal rights risk to persons in care.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 infant under 12 months old did not have the LIC9227 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
1
2
3
4
The LIcensee shall send a completed LIC9227 to the LPA no later than November 14, 2023.
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:
Mayla Mendoza
TELEPHONE:
(510) 292-9724
LICENSING EVALUATOR NAME:
Indira Loza
TELEPHONE:
510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE:
10/17/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/17/2023
LIC809
(FAS) - (06/04)
Page:
8
of
12