191604592-2-7-2023-54-CC-MAYA-CNTV4F-20230207150615

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191604592
Report Date: 02/07/2023
Date Signed: 02/07/2023 03:06:39 PM

Document Has Been Signed on 02/07/2023 03:06 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	SERNA FAMILY DAY CARE		FACILITY NUMBER:	191604592
ADMINISTRATOR:	SERNA, MADELINE ANN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 602-1188
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90712
CAPACITY:	14	CENSUS: 3	DATE:	02/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Licensee's Assistant, Paris Serna		TIME COMPLETED:	03:15 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	On February 7, 2023 at 12:30 PM, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced inspection at the facility noted above and met with Licensee's Assistant, Paris Serna. Per Licensee's Assistant, Licensee, Madeline Serna is currently on vacation (out of the country) and will be returning on Saturday, February 11th. The purpose of the inspection was to conduct the Required - 1 Year inspection. The operating hours of the facility is Monday through Friday from 6:00 AM to 6:00 PM. Entrance Checklist (LIC 126) was provided to the Licensee's Assistant upon arrival. Individuals residing in the home were discussed and noted. At the time of the inspection, Licensee's Assistant and three (3) napping children were present. LPA conducted a tour of the inside and outside of the facility accompanied by Licensee's Assistant, Paris Serna. This facility is a single family home that consists of 3 bedrooms, two (2) bathrooms, daycare room, living room, dining room, kitchen, fenced backyard, fenced driveway, and detached garage. Areas that are accessible to children include: one (1) bathroom, daycare room, and fenced driveway. Per Licensee's Assistant, the children utilize the fenced driveway for outdoor activity. Areas off-limits to children include: 3 bedrooms, 1 bathroom, living room, dining room, kitchen, fenced backyard, and detached garage. LPA observed a child safety gate installed in the kitchen pathway to the daycare room, making the "off-limit" areas inaccessible to children in care. LPA observed the children having direct access to 1 bathroom and the gated driveway from the daycare room. LPA observed a gate closed and locked, making the fenced backyard inaccessible to children in care. LPA also observed the garage door closed, making the space inaccessible. Licensee's Assistant was advised that off-limit areas must be made inaccessible during operating hours or while children in care are present.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SERNA FAMILY DAY CARE	FACILITY NUMBER: 191604592
	VISIT DATE: 02/07/2023

NARRATIVE

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The following documents were posted in a prominent, publicly accessible area: Facility License, Emergency Disaster Plan (LIC 610A), and Facility Roster (LIC 9040). LPA did not observe the required Notification of Parents' Rights (PUB 394) posted. Licensee's Assistant was unable to provide verification of Disaster and Fire Drills for review.

Areas used by children were inspected for safety, comfort, heating, cleanliness and telephone service. The home does not have any wall heaters or fireplaces. Detergents, cleaning compounds, and medicines were made inaccessible to children. Per Licensee's Assistant, there are no poisons kept in the home. Licensee's Assistant was advised that if any poisons are purchased, it is required to be locked with a key or combination lock.

Per Licensee's Assistant, the home has a fish tank and 1 dog. LPA advised that best practice is to keep pets isolated from children in care. Per Licensee's Assistant, there are no bodies of water, firearms and/or weapons on the premises. LPA observed age appropriate toys and napping equipment for children. LPA also observed electrical outlet covers installed in the child care areas. Per Licensee's Assistant, snacks and meals are provided to the children by the facility. Licensee's Assistant was informed that any food that is brought from the child's home shall be labeled with the child’s name and properly stored or refrigerated.

LPA observed the required fire extinguisher (2-A:10-B:C or larger) that is fully charged and last serviced on February 4, 2022. Licensee's Assistant was informed that the fire extinguisher must be serviced yearly. Smoke detector and carbon monoxide detector was tested and is operable. First Aid kit and emergency supplies are available and kept in the daycare room.

LPA conducted a record review of 3 children's records and 2 personnel records. Based on the children's record review, 1 out of 3 children (C2) did not have their immunization record available for review. LPA also found that children (C1 and C3) did not have verification of the 15-minute physical checks while children are napping available for review. Based on the personnel record review, Licensee's Assistant did not have a Pediatric First Aid and CPR certification (EMSA-approved), proof of immunization for measles and pertussis (or documentation of exemption), TB clearance (or risk assessment), and Employees Rights (LIC 9052) available for review.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SERNA FAMILY DAY CARE	FACILITY NUMBER: 191604592
	VISIT DATE: 02/07/2023

NARRATIVE

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Based on Licensee's record review, Licensee has proof of immunization against measles, pertussis, influenza, and a TB clearance. Licensee has a current Pediatric First Aid and CPR certification (expires April 2024). Licensee did not have the Preventative Health and Safety Practices (EMSA-approved) certificate of completion available for review. Licensee completed the Mandated Reporter Training (AB 1207) on May 11, 2022. Licensee's Assistant was advised that the Mandated Reporter training (AB 1207) must be completed every 2 years and is available at www.mandatedreporterca.com.

LPA discussed the safe sleep regulations with Licensee's Assistant 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's Assistant 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.

Licensee's Assistant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PINs), Program Quarterly Update Newsletters and other important information communication platforms.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SERNA FAMILY DAY CARE	FACILITY NUMBER: 191604592
	VISIT DATE: 02/07/2023

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/inspection-process.

Deficiencies were cited during today's inspection (refer to deficiency pages).

During the inspection, LPA requested the following documents be submitted to LPA via e-mail by Tuesday, February 14th: updated Application (LIC 279), updated Current Children in your Home (LIC 279B), and updated Facility Sketch (LIC 999A).

A Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Licensee's Assistant, Paris Serna.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/07/2023 03:06 PM - It Cannot Be Edited

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SERNA FAMILY DAY CARE	FACILITY NUMBER: 191604592
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)1

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the Licensee's Assistant was unable to provide written verification of fire and disaster drills for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2023
	Plan of Correction
1 2 3 4	Licensee will conduct a fire and disaster drill, and submit proof of completion to LPA via e-mail by March 7, 2023.

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: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/07/2023 03:06 PM - It Cannot Be Edited

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SERNA FAMILY DAY CARE	FACILITY NUMBER: 191604592
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as Licensee's Assistant did not have proof of immunization for measles, pertussis, and a TB clearance available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2023
	Plan of Correction
1 2 3 4	Licensee's Assistant will obtain the required documentation for their immunization record, and Licensee will submit proof of completion to LPA via e-mail by March 7, 2023.

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as Licensee's Assistant did not have a Pediatric First Aid/CPR certification (EMSA-approved), and both Licensee's Assistant and Licensee did not have the Preventative Health and Safety Practices (EMSA-approved) certificate of completion available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2023
	Plan of Correction
1 2 3 4	Licensee will submit current and valid certifications for the noted training courses to LPA via e-mail by March 7, 2023.

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: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/07/2023 03:06 PM - It Cannot Be Edited

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SERNA FAMILY DAY CARE	FACILITY NUMBER: 191604592
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416.1(a)(10)

Personnel Records

(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as Licensee's Assistant did not have the Employee Rights (LIC 9052) available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2023
	Plan of Correction
1 2 3 4	Licensee will submit the completed LIC 9052 for Licensee's Assistant to LPA via e-mail by March 7, 2023.

Type B

Section Cited

CCR

102419(b)

Admission Procedures and Authorized Representatives Rights

(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the facility did not have the Notification of Parents' Rights Poster (PUB 394) posted which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2023
	Plan of Correction
1 2 3 4	Licensee will post the required PUB 394 in a prominent, publicly accessible area in the facility, and submit proof of completion to LPA via e-mail by March 7, 2023.

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: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

Page: 7 of 9

Document Has Been Signed on 02/07/2023 03:06 PM - It Cannot Be Edited

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SERNA FAMILY DAY CARE	FACILITY NUMBER: 191604592
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)

Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 3 children's records (C2) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2023
	Plan of Correction
1 2 3 4	Licensee will obtain a copy of the immunization record for child (C2), and submit proof of completion to LPA via e-mail by March 7, 2023.

Type B

Section Cited

CCR

102425(j)(2)(D)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 2 children's records (C1 and C3) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2023
	Plan of Correction
1 2 3 4	Licensee will maintain a log of 15-minute physical checks while C1 and C3 are napping, and submit written verification for at least one week to LPA via e-mail by March 7, 2023.

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: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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