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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115405760
Report Date: 12/14/2023
Date Signed: 12/14/2023 10:00:23 AM


Document Has Been Signed on 12/14/2023 10:00 AM - 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926



FACILITY NAME:ACEVEDO, MARISOL FAMILY CHILD CARE HOMEFACILITY NUMBER:
115405760
ADMINISTRATOR:ACEVEDO, MARISOLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 988-6261
CITY:ORLANDSTATE: CAZIP CODE:
95963
CAPACITY:14CENSUS: 7DATE:
12/14/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Marisol AcevedoTIME COMPLETED:
10:10 AM
NARRATIVE
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On 12/14/23 at 8:01 am, an annual inspection was made to the facility by Licensing Program Analyst (LPA), Mendez. At 9:06 am the home was toured inside and outside. The licensee was supervising 7 children, and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 5am-5pm, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are three bedrooms and garage, and were made inaccessible by door knob covers. The children use the back yard as the outdoor play area and it is fully fenced.

Seven children's records were reviewed at 8:06am. One staff record was reviewed at 8:31am. There are currently four adults living in the home.

The following deficiencies were cited: Based on record review, Licensee's Mandated reporter training was not on file for review, 2 of 7 children's files reviewed were missing documentation which included identification information card parents right and consent for medical treatment, updated roster of the children enrolled, licensee did not have proof of vaccinations and tb test on file.



SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: ACEVEDO, MARISOL FAMILY CHILD CARE HOME
FACILITY NUMBER: 115405760
VISIT DATE: 12/14/2023
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

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 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-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] 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.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: ACEVEDO, MARISOL FAMILY CHILD CARE HOME
FACILITY NUMBER: 115405760
VISIT DATE: 12/14/2023
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee , confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Marisol Acevedo
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 12/14/2023 10:00 AM - 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: ACEVEDO, MARISOL FAMILY CHILD CARE HOME
FACILITY NUMBER: 115405760

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the licensee did not comply with the section cited above in which licensee did not have a current updated mandated training which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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Licensee will complete mandated reporter training on mandatedreporterca.com and submit proof of completed to CCLD to LPA by 12/27/23
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee was unable to provide proof of documentation for influenza, tdap, mmr and tb test on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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Licensee will submit proof of vaccines to CCLD by 12/27/23
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: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 12/14/2023 10:00 AM - 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: ACEVEDO, MARISOL FAMILY CHILD CARE HOME
FACILITY NUMBER: 115405760

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023

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
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Based on record review, 2 of 7 children (C1&C7) were missing a copy of emergency information card as required which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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LIcensee will submit copy as proof that C1 and C7 have a emergency information card on file and will submit proof to CCLD by 12/27/23
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, currentl enrolled children were not listed on the roster which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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Licensee will submit proof to CCLD a most current copy of the child care roster by 12/27/23
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: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 12/14/2023 10:00 AM - 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: ACEVEDO, MARISOL FAMILY CHILD CARE HOME
FACILITY NUMBER: 115405760

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023

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
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Based on record review, 2 of 7 (C1&C7) children's files were missing documentation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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Licensee will submit proof that children C1 and C7 have missing documentation on file and submit proof to CCLD by 12/2723.

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: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6