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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103901483
Report Date: 06/27/2019
Date Signed: 06/27/2019 04:30:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:MORENO, AGUSTINA FAMILY CHILD CAREFACILITY NUMBER:
103901483
ADMINISTRATOR:MORENO,AGUSTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 626-7134
CITY:ORANGE COVESTATE: CAZIP CODE:
93646
CAPACITY:14CENSUS: 10DATE:
06/27/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Agustina MorenoTIME COMPLETED:
12:35 PM
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"Spanish speaker" Licensing Program Analyst (LPA) Diana Martinez conducted an unannounced annual/random inspection. LPA met with licensee Agustina Moreno. Also present was assistant/husband Jose Resendez. Ten children were present today. LPA conducted an interior and exterior tour of the home. The accessible rooms are the living room, bedroom, dining area, kitchen, and bathroom. The off-limit rooms are made inaccessible with a safety latch eye and hook and barrel slide bolt locks. Safe, healthful, and comfortable accommodations, furnishings, and equipment were observed. Licensee does not have any pets. There are no bodies of water or firearms in this home. No poisons were observed on the premises. Cleaning compounds, medications and other hazardous items are inaccessible to children. There is no fireplace. There is a working fire extinguisher, smoke detector, carbon monoxide indicator, and adequate heating and ventilation for safety and comfort. There are no stairs in the home. There is a working landline telephone and number was verified. Adequate supervision is being provided during this visit. Capacity as specified on the license is being maintained. Licensee is aware that a current roster of the children in care is to be maintained. Licensee maintains documentation of immunizations for the children. Licensee maintains documentation of immunizations against pertussis, measles and influenza for herself and assistant. Pediatric CPR/First Aid are current with the expiration date of 3/2021.

LPA discussed Incidental Medical Services (IMS) policy and provided handout Plan for Providing Incidental Medical Services (IMS) – FCCH Requirements. 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. (See next page)

SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Diana D MartinezTELEPHONE: (559) 341-4670
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2019
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: MORENO, AGUSTINA FAMILY CHILD CARE
FACILITY NUMBER: 103901483
VISIT DATE: 06/27/2019
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Licensee has provided parents with a copy of the Identification and Emergency Information form (LIC 700). Licensee is aware that fire drills are to be conducted and documented with the date and time every six months. Licensee is aware that children are never to be left in parked vehicles. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. Licensee is aware that upon notice from the Department, any excluded individual must be immediately removed from the home and prevented from returning to the home or having contact with children in care. Licensee is aware that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice.

Days and hours of operation are Monday – Friday from 4:30 AM – 6:00 PM and Saturdays 4:30 AM – 3:00 PM.

Licensee indicated that she will install a large wooden play structure in approximately one month to replace the various plastic play structures. LPA advised licensee that she may install the play structure provided that manufacturer’s installation instructions are followed and once in place to contact LPA as a visit will be required to ensure structure is safe for children’s use. Licensee will have it installed when day care children are not present.

LPA reviewed and provided information to licensee regarding safe sleep, lead exposure, parents’ board, children's files and instructions on accessing PINs and quarterly updates. Licensee was also provided with a packet of licensing forms and a fire drill log.

Per California Code of Regulations, Title 22, Division 12, Chapter 3, no deficiencies cited during today's visit.

An exit interview was conducted with licensee Agustina Moreno and a copy of this report was provided and discussed. A Notice of Site Visit Form (LIC 9213) was posted on parent's board and must remain posted for 30 days.
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Diana D MartinezTELEPHONE: (559) 341-4670
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2019
LIC809 (FAS) - (06/04)
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