153801391-7-3-2019-04-CC-GRES-BDQTH2-20190703144401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 153801391
Report Date: 07/03/2019
Date Signed: 07/03/2019 02:44:08 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:	GLENWOOD MIGRANT HEAD START		FACILITY NUMBER:	153801391
ADMINISTRATOR:	GAMINO, LORENA		FACILITY TYPE:	850
ADDRESS:	625 14TH AVENUE		TELEPHONE:	(661) 720-9550
CITY:	DELANO	STATE: CA	ZIP CODE:	93215
CAPACITY:	92	CENSUS: 70	DATE:	07/03/2019
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Lorena Gamino		TIME COMPLETED:	03:15 PM

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This case management visit is conducted by Licensing Program Analyst, (LPA) Gloria Reyes for the purpose of verifying that all of the requirements are in accordance with Sections 101214, 101215, 101216, 101218, 101218.1, 101219, 101226, and 101226.3 of Title 22 Regulations before a child receives G-tube care at this facility. On 06/25/19, in accordance with Section 101173(c), the licensee notified the Department of their intent to provide G-tube care and to obtain approval from the Department to provide this care to child #1 listed on LIC811. The documentation in file and newly provided documentation are in accordance with Sections 101173(c) and 101173(b)(5).

Licensee is reminded of the following:

1. In accordance with California Code of Regulations, Title 22, Section 101216(a), the licensee must ensure that staff who administer G-tube feeding to the child are competent to do so and staff who provide G-tube care must be at least 18 years old. It is noted that child’s physician designated Glenwood Migrant Head Start as the Child Care Facility providing G-tube feeding and/or liquid medication through G-tube.

2. In accordance with California Code of Regulations, Title 22, Section 101226(e)(3), the written instructions must be updated annually, or whenever the child’s needs dictate (for example, if the child obtains a different type of G-tube or if the frequency of feeding and amount/type of formula or liquid medication to be administered to the child changes). The written instructions can only be updated by the child’s physician or a health care provider working under the supervision of the child’s physician. In addition, the written instructions must include specific, explicit steps for a layperson to administer G-tube feeding or liquid medication to the child and provide related necessary care. This includes, but may not be limited to, the following:

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SUPERVISOR'S NAME: Alice Juarez	TELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Gloria Reyes	TELEPHONE: (559) 341-4471
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2019

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GLENWOOD MIGRANT HEAD START	FACILITY NUMBER: 153801391
	VISIT DATE: 07/03/2019

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a. Any limitations or modifications to normal activity required by the presence of the G-tube.

b. Frequency of feeding and amount/type of formula or liquid medication to be administered to the child in accordance with the physician’s prescription.

c. Hydration of the child with water or other liquids as determined by the child’s physician.

d. Method of feeding, administering liquid medication or hydrating the child, including how high the syringe is to be held during the feeding. If applicable, this includes how to use an enteral (means “into the stomach”) feeding pump.

e. Positioning of the child.

f. Potential side effects, e.g., nausea, vomiting, abdominal cramping. (Decompression - the removal of gas in the gastrointestinal tract - is not to be performed on the child beyond briefly removing the cap from the gastric feeding button. Pressing on the child’s stomach to try and remove air may harm the child and should not be done. However, the cap may be taken off the gastric feeding button for a brief time only, which may or may not help relieve gas in the child.)

g. Specific actions to be taken in the event of specific side effects or an inability to complete a feeding, administration of liquid medication to the child, or hydration of the child in accordance with the physician’s prescription. This includes actions to be taken in an emergency.

h. How and when to flush out the G-tube with water, including what to do if the G-tube becomes clogged. Specific instructions on how many cc’s of water to use when flushing out the G-tube.

i. Instructions for proper sanitation, including care and cleaning of the stoma site.

j. Instructions for proper storage of the formula or the liquid medication [California Code of Regulations, Title 22, Section 101226(e)(1)].

k. Instructions for proper care and storage of equipment.

SUPERVISOR'S NAME: Alice Juarez	TELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Gloria Reyes	TELEPHONE: (559) 341-4471
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2019

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: GLENWOOD MIGRANT HEAD START	FACILITY NUMBER: 153801391
	VISIT DATE: 07/03/2019

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g. A copy of the G-tube manufacturer’s instructions. Included in the child’s file at the facility. (Note: If there is a conflict between the physician’s instructions and the manufacturer’s instructions, the physician’s instructions should always be followed.)

h. Record of administration of G-tube feedings, liquids (hydration) and liquid medications. Included in the child’s file at the facility. This documentation must be kept in the child’s records, be provided to the child’s authorized representative on a daily basis, and be available to licensing representative upon request.

Licensee is also reminded that staff must ensure that the child’s needs and the needs of the other children in care are met. This includes ensuring that trained back-up staff is available to assist the child if necessary. Licensee states qualified assistants listed on LIC811 will provide assistance to ensure that the needs of the other children in care are met. In addition, Licensee must notify the Department each time she accepts another child who needs G-tube care.

In exit interview, above summary of record requirements, regulations, and recommendations were discussed in detail.

Per documentation submitted, Licensee is in accordance with Sections 101214, 101215, 101216, 101218, 101218.1, 101219, 101226, and 101226.3 to provide care and supervision to G-tube child #1 listed on LIC811 at Glenwood Migrant Head Start Child Care Center, effective July 15, 2019.

SUPERVISOR'S NAME: Alice Juarez	TELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Gloria Reyes	TELEPHONE: (559) 341-4471
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2019

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: GLENWOOD MIGRANT HEAD START	FACILITY NUMBER: 153801391
	VISIT DATE: 07/03/2019

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l. The telephone number and address of the child’s physician or designee.

The following is a summary of all of the items that must be on file with regard to providing G-tube care in a licensed Child Care Center:

a. Licensee’s statement of intent to provide G-tube care, including a statement on how staff are to be trained in G-tube care. Included with the program materials (Plan of Operation) in the office file.

b. Written permission from the child’s authorized representative for the licensee or designated staff member(s) to provide G-tube care to the child. The Gastrostomy-Tube Care Consent/Verification – Child Care Facilities (LIC 701B) form is to be used for this purpose. A separate LIC 701B must be on file for EACH person who provides G-tube care to the child. Included in the child’s file and in each respective employee’s personnel file at the facility.

c. Physician’s written designation of person deemed competent to provide instruction in G-tube care. The Gastrostomy-Tube Care: Physician’s Checklist (Child Care Facilities) (LIC 701A) form has space for this information. Included in the child’s file at the facility.

d. Written verification of the licensee’s or employee’s completion of instruction in G-tube care. Included in each respective employee’s personnel file at the facility.

e. Child’s medical assessment, including the physician’s assessment of the appropriateness of providing G-tube care to the child. The Physician’s Report – Child Care Centers (LIC 701) and the Gastrostomy-Tube Care: Physician’s Checklist (Child Care Facilities) (LIC 701A) are to be used to document this information. Included in the child’s file at the facility.

f. Written instructions from the physician, with any updates attached. Should be attached to the Gastrostomy-Tube Care: Physician’s Checklist (Child Care Facilities) (LIC 701A). Included in the child’s file at the facility.

SUPERVISOR'S NAME: Alice Juarez	TELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Gloria Reyes	TELEPHONE: (559) 341-4471
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2019

LIC809 (FAS) - (06/04)

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