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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125407875
Report Date: 02/24/2022
Date Signed: 03/17/2022 12:47:30 PM


Document Has Been Signed on 03/17/2022 12:47 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926



FACILITY NAME:MALDONADO VARGAS, BERTHA FAMILY CHILD CARE HOMEFACILITY NUMBER:
125407875
ADMINISTRATOR:MALDONADO VARGAS, BERTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 599-0604
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY:14CENSUS: 6DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Bertha Madonado VargasTIME COMPLETED:
10:35 AM
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On 2/24/2022 at 9:15am, an annual inspection was made to the facility by Licensing Program Analyst (LPA), Mendez. At 10:15am the home was toured inside and outside. The licensee was supervising six 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 top floor where four bedrooms are located and were made inaccessible by baby gate. The kitchen is off limits and made inaccessible by baby gate. The children use the back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard.

Six children's records were reviewed at 9:30am. Two staff records were reviewed at 9:50am. Licensee's CPR/First Aid is current and expires 2/2023. PHP was completed on 06/09/2021. Mandated Reporter Training was completed and expires on 08/16/2023.

There are currently two adults living in the home. The Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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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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: MALDONADO VARGAS, BERTHA FAMILY CHILD CARE HOME
FACILITY NUMBER: 125407875
VISIT DATE: 02/24/2022
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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 [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.

Incidental Medical Services (IMS) policy was discussed. 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

There were no deficiencies cited during today’s inspection.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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