103906269-4-22-2022-04-CC-AGIN-CDQS83-20220422133829

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 103906269
Report Date: 04/22/2022
Date Signed: 04/22/2022 05:57:34 PM

Document Has Been Signed on 04/22/2022 05:57 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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	MONTIEL, NICOLE FAMILY CHILD CARE		FACILITY NUMBER:	103906269
ADMINISTRATOR:	MONTIEL, NICOLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(559) 321-3656
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	14	CENSUS: 6	DATE:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jazmine Gens		TIME COMPLETED:	01:50 PM

NARRATIVE

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On 4/22/22 Licensing Program Analysts (LPA), Araceli Gibson conducted an unannounced Annual Required Inspection and was met by Staff (2) who allowed LPA entry while Licensee was on her way to the facility. LPA did her tour with Staff (2). Days and hours of operation are Monday-Friday from 7:00 AM - 4:30 PM.

LPA toured the home inside and outside and a census of 6 children was taken. Current facility sketch reviewed, and Licensee confirmed that the kitchen, bathroom, living room, family room, dining room, and outdoor play yard are used for providing care and are accessible to children. Master bedroom, Bedroom 1 and 2 are off-limits and made inaccessible by use of doorknob covers. Swimming pool is fenced per regulation. The pool gate is self-latching, self-closing and opens away from the swimming pool. No windows or doors have direct access to the pool area. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The fireplace located in the family room and is made inaccessible by a screen . Fireplace will not be in use during daycare hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the cell phone number is (559) 321-3656.

LPA discussed Safe Sleep Regulations with licensee. Play yards and cribs are not being used as infants are over 12 months of age. Licensee is aware that for each infant in care, cribs and play yards are to be kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Licensee physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping. Continue 809C

SUPERVISOR'S NAME: Susie Fanning	TELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Araceli Gibson	TELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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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Document Has Been Signed on 04/22/2022 05:57 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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: MONTIEL, NICOLE FAMILY CHILD CARE	FACILITY NUMBER: 103906269
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 for two chidlren's files out of 6. Licensee did not have a file for child 6, child 5 was missing emergency consent signature from authorized representative which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/06/2022
	Plan of Correction
1 2 3 4	Licensee agrees to get a complete file for the child 6 complete with immunizations, LIC 627, LIC700 and a signed LIC627 for Child 5.

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: Susie Fanning	TELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Araceli Gibson	TELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/22/2022 05:57 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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: MONTIEL, NICOLE FAMILY CHILD CARE	FACILITY NUMBER: 103906269
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2022

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 Licensee did not a signed consent of LIC 995E in file for child 6. which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/06/2022
	Plan of Correction
1 2 3 4	Licensee agrees to get a complete file for the child 6 to include form LIC 995E.

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: Susie Fanning	TELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Araceli Gibson	TELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: MONTIEL, NICOLE FAMILY CHILD CARE	FACILITY NUMBER: 103906269
	VISIT DATE: 04/22/2022

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Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files 2 files were incomplete with emergency information as required.(See 809D) Licensee’s Mandated Reporter General training was completed on 08/2020. LPA advised she needs to fully complete the Mandated Reporter Training for Childcare providers AB1207. Staff (2) did have the Mandated Reporter Training for Child care providers AB1207completed on 08/15/20 in file. Licensee and staff (2) had the pediatric CPR/First Aid with expiration of 07/07/22. A review of records indicates that Licensee and Staff (2) had immunization records for pertussis, measles and flu in file.

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.

Incidental Medical Services (IMS) is not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Susie Fanning	TELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Araceli Gibson	TELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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