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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125407570
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:29:25 PM

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:PEREZ, JENSHEN FAMILY CHILD CARE HOMEFACILITY NUMBER:
125407570
ADMINISTRATOR:PEREZ, JENSHENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 798-7102
CITY:EUREKASTATE: CAZIP CODE:
95503
CAPACITY:14CENSUS: 13DATE:
07/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jenshen PerezTIME COMPLETED:
03:00 PM
NARRATIVE
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On 07/22/21 at 11:30AM, Licensing Program Analyst (LPA) Lynch conducted an a case management inspection to the facility, and met with the Licensee. The case management visit was conducted regarding an incident at the facility reported on 07/15/21. Licensee also self-reported and was forthcoming about the incident from 07/14/21. Licensee stated her and her spouse/assistant were doing laundry on the day of the incident, and were washing children's sheets and bedding, and were using the third empty play yard for storage in the infant nap room. Licensee stated her spouse tossed the clean sheets and pads into the empty play yard to fold for later, but a mattress pad had fallen on the floor. Licensee stated when he went back into the room to check on the two sleeping infants, he saw the mattress pad on the floor, and inadvertently draped the pad over the side of the play yard where an infant was sleeping thinking he would be right back to get the bedding for the laundry. Licensee stated when he went back in the nap room approximately 15 minutes later, he discovered the infant with the mattress pad around their head, and when the pad was removed the infant appeared to be limp and infant's skin was a grayed tone. Licensee stated infant's eyes were still moving around and was still breathing, but was gasping. Licensee's spouse also confirmed the events. Licensee stated they immediately started CPR and contacted 9-1-1, and the infant started moving their limbs and infant's skin became pink in tone. Licensee stated the infant's parents were contacted and the infant was taken to the hospital and survived. Licensing received the hospital report on 07/15/21 regarding the infant which stated the infant survived and currently has normal vitals. Licensee stated the infant has been released back into their care at the request of the parents.

TYPE A - The following violation of the California Code of Regulations, Title 22, Division 12, was cited: see LIC 9099-D. Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled, and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC 9224 to be kept in each child's file. Appeal rights were provided and exit interview conducted. Notice of Site Visit shall be posted for 30 days from today’s visit. All licensing reports are public information and must be made available upon request for at least three years.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Kiriko LynchTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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: PEREZ, JENSHEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 125407570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2021
Section Cited

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Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.
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This requirement was not met as evidenced by the Licensee's statement of the incident where a mattress pad was draped over the play yard side and subsequently became wrapped around infant's head during naptime.
Civil penalty will also be assessed.
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Licensee and staff will also have a virtual meeting to review current FCCH Safe Sleep regulations. Licensee will submit a written and signed statement by all staff attesting they watched, reviewed, and will follow currently safe sleep regulations. Licensee will submit the signed statement to Licensing by POC due date.

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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: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Kiriko LynchTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021
LIC809 (FAS) - (06/04)
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