191513975-4-28-2023-33-CC-JMOA-CRBR8V-20230428124835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191513975
Report Date: 04/28/2023
Date Signed: 04/28/2023 12:48:58 PM

Document Has Been Signed on 04/28/2023 12:48 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	HERNANDEZ FAMILY CHILD CARE		FACILITY NUMBER:	191513975
ADMINISTRATOR:	HERNANDEZ, MARICRUZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(909) 627-1747
CITY:	POMONA	STATE: CA	ZIP CODE:	91766
CAPACITY:	14	CENSUS: 2	DATE:	04/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Maricruz Hernandez		TIME COMPLETED:	01:05 PM

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	Licensing Program Analyst's (LPA) Judy Mora and Mary Silva conducted an unannounced annual required inspection at the above facility on 04/28/23 at 11:10 PM. Licensing staff met with Maricruz Hernandez, Licensee, who guided licensing staff on a tour of the home. There was 2 children in care and the Licensee's biological two adult children, Andrea Hernandez and Luis Hernandez were present. Visit was conducted in Spanish. Family members residing in the home are the 3 adults (criminal record clearance on file) and 0 children. This is a one story home which consists of 3 bedrooms, 2 bathrooms, kitchen, living room, dining room, laundry room, play room, front yard, backyard (fenced) and garage. The children use the bathroom in the hallway, play room, dining room, living room, kitchen area, backyard. Per licensee, areas off limits to children and parents include: 3 bedrooms,1 bathroom, front yard, back yard garden, and garage. Licensing staff toured all areas used by children during this visit. Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There is a fireplace in the living room which is inaccessible. There are toys available for children. There is a working telephone service maintained in the home. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible. All food items are prepared by in the home. Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicates fully charged, serviced 11/25/22. Currently children use backyard for outdoor play. The outdoor play area was observed to be fenced. LPA did not observe any objects that could be hazardous to children in care. Report continues on next page

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy Mora	TELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: HERNANDEZ FAMILY CHILD CARE	FACILITY NUMBER: 191513975
	VISIT DATE: 04/28/2023

NARRATIVE

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Licensing staff observed the following required posted documentation in the playroom: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form. LPA reviewed facility records for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill documented was 01/2023. Licensee states that there are currently 03 children enrolled, children's roster was reviewed and is current.

Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in the family room, if necessary, away from the other children. Per Licensee there are no firearms or weapons stored in the home.

Infant Care: The facility is not caring for infants.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, LPA(s) did not observed Immunization's in any of the children's files, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights,

Staff records were reviewed for approved Pediatric First Aid and CPR certification. The Licensee does not have a current certificate on file. LPA reviewed the LIC 508- Criminal Record Statement. Licensee doesn't have Proof of immunization's against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate.

Incidental Medical Services (IMS) policy was discussed. Per Licensee, there are no children on medications. 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Report continues on next page

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy Mora	TELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: HERNANDEZ FAMILY CHILD CARE	FACILITY NUMBER: 191513975
	VISIT DATE: 04/28/2023

NARRATIVE

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To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com. The Licensee will complete the training.

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.

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 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.

There are no deficiencies being cited. Technical violations were issued.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Licensee, Maricruz Hernandez.

*END OF REPORT

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy Mora	TELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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