163809054-10-4-2019-04-CC-KPAO-BGMLTF-20191004090216

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 163809054
Report Date: 10/03/2019
Date Signed: 10/04/2019 09:02:21 AM

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:	SANDOVAL FAMILY CHILD CARE		FACILITY NUMBER:	163809054
ADMINISTRATOR:	SANDOVAL, MARTHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(559) 589-0159
CITY:	HANFORD	STATE: CA	ZIP CODE:	93230
CAPACITY:	14	CENSUS: 10	DATE:	10/03/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Martha Sandoval		TIME COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this date, Licensing Program Analyst (LPA) Kathy Pacheco conducted an unannounced annual/random inspection. LPA met with Licensee, Martha Sandoval, who provided a tour of the home, inside and outside, as shown on the facility sketch. The swimming pool is fenced per regulation. There are no firearms in the home. Poisons, cleaning compounds, medications and other hazardous items are inaccessible to children. The fireplace is in an off-limits room and is inaccessible to children. The fire extinguishers, smoke detectors, and carbon monoxide indicator meet Community Care Licensing (CCL) regulations. The home is kept clean and orderly, with heating and ventilation for safety and comfort. There are no stairs in the home. Safe toys and play equipment are observed. There are no animals in the home. Licensee has a working telephone and the above telephone number was verified. Adequate supervision is being provided during this inspection. Outdoor play areas are fenced or supervised by the Licensee or care giver. Capacity as specified on the license is being maintained. Staff-child ratios are maintained. Children’s records contain all emergency information specified by regulation. All adults who reside or work in the home have a criminal record clearance or exemption as indicated on LIS 531 – Facility Personnel Report Summary, with the exception of Licensee's son (A1) (See Confidential Names List (LIC 811) dated 10/3/19) who recently turned 18 years old. LPA observed the son at the home and Licensee stated he lives in the home. Licensee is aware she needs to have him fingerprint cleared immediately per California Code of Regulations, Section 102370(d)(1): (d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. Incidental Medical Services (IMS) policy was discussed. Licensee is aware that an IMS plan is required to be submitted to the Licensing office if they provide any of these services. (continued on next page)

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Kathy Pacheco	TELEPHONE: (559) 341-5116
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2019

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: SANDOVAL FAMILY CHILD CARE	FACILITY NUMBER: 163809054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/04/2019 Section Cited	1 2 3 4 5 6 7	(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall. . . (1) Obtain a California clearance or a criminal record exemption as required by the Department. (e) Violation of Section 102370(d) will result in a citation of a deficiency and an immediate
	8 9 10 11 12 13 14	assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the Department. This requirement was not met as evidenced by Licencee's son (A1) not fingerprint cleared (see LIC 809). This poses an immedidate risk to the health, safety, or personal right of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Kathy Pacheco	TELEPHONE: (559) 341-5116
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2019

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: SANDOVAL FAMILY CHILD CARE	FACILITY NUMBER: 163809054
	VISIT DATE: 10/03/2019

NARRATIVE

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The Licensee and other personnel as specified have completed training on preventative health practices including pediatric CPR and first aid; Expires: 10/13/20. Licensee provided proof of required immunization (Pertussis/Measles/Influenza) and/or written declaration declining flu shot for all staff. Licensee also provided proof of required Mandated Reporter Training; Completed: 1/16/18.

LPA provided Licensee with information regarding the California Department of Social Services (CDSS) Provider Information Notices (PINs) communication system; information regarding Safe Sleep Regulations; AB 2370, Chapter 676, Statutes of 2018, requiring child care providers to inform parents and/or guardians with lead safety information, and other important resources and information links offered on the CDSS website.

Business hours are Monday through Friday 4:30 AM to 5:00 PM and other hours as arranged.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, the following deficiency is found: (see next page)

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.

Any Licensing reports indicating a Type A deficiency shall be posted immediately and for the next 30 days and copies provided of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Health & Safety Section 1596.859(a) shall be cited and a civil penalty of $100.00 for failure to provide copies to parents/guardians of children in care and newly enrolled children, and for failure to maintain written verification of receipt of licensing reports indicating a Type A violation (LIC 9224).

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Kathy Pacheco	TELEPHONE: (559) 341-5116
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2019

LIC809 (FAS) - (06/04)

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