191609210-11-4-2022-54-CC-MAYA-CKUS8D-20221104133859

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191609210
Report Date: 11/04/2022
Date Signed: 11/04/2022 01:39:20 PM

Document Has Been Signed on 11/04/2022 01:39 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:	CALDERON FAMILY DAY CARE		FACILITY NUMBER:	191609210
ADMINISTRATOR:	CALDERON, CHERYL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 804-4644
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90713
CAPACITY:	12	CENSUS: 1	DATE:	11/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Licensee, Cheryl Calderon		TIME COMPLETED:	01:45 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 November 4, 2022 at 11:40 AM, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced inspection at the facility noted above and met with Licensee, Cheryl Calderon. The purpose of the inspection was to conduct the Required - 1 Year inspection. The operating hours of the facility is Monday through Friday from 7:00 AM to 5:30 PM. Entrance Checklist (LIC 126) was provided to the Licensee upon arrival. Individuals residing in the home were discussed and noted. At the time of the inspection, one (1) child was present. All areas identified on the facility sketch were inspected. This facility is a single family home that consists of three (3) bedrooms, 1 bathroom, living room, dining room, family room, kitchen, attached garage, and fenced backyard. Areas that are accessible to children include: two (2) bedrooms, 1 bathroom, living room, dining room, family room, kitchen, and fenced backyard. Per Licensee, the children utilize the fenced backyard for outdoor activity. Areas off-limits to children include: 1 bedroom and attached garage. LPA observed the door leading into the garage from the family room was closed and locked, making the area inaccessible to children in care. LPA also observed the bedroom door closed with a child safety knob attached, making the off-limit bedroom inaccessible to children in care. Licensee was advised that off-limit areas must be made inaccessible during operating hours or while children in care are present. The following documents were posted in a prominent, publicly accessible area: Facility License, Notification of Parents' Rights (PUB 394), Earthquake Preparedness (LIC 9148), Emergency Disaster Plan (LIC 610A), and Facility Roster (LIC 9040). Licensee did not have verification of Disaster and Fire Drills 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: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CALDERON FAMILY DAY CARE	FACILITY NUMBER: 191609210
	VISIT DATE: 11/04/2022

NARRATIVE

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Areas used by children were inspected for safety, comfort, heating, cleanliness and telephone service. The home has wall heaters located in the dining room area and hallway. LPA observed the wall heaters barricaded, making them inaccessible to children in care. The home does not have any fireplaces. Detergents, cleaning compounds and medicines were made inaccessible to children. Per Licensee, there are no poisons kept in the home. Licensee was advised that if any poisons are purchased, it is required to be locked with a key or combination lock. Per Licensee, there are no pets, 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.

LPA observed the required fire extinguisher (2-A:10-B:C) that is fully charged and was purchased on October 26, 2022. Licensee was reminded to have the fire extinguisher serviced yearly. Smoke detector and carbon monoxide detector were tested and are operable. First Aid kit and emergency supplies are available and kept in a closet located in the hallway. Licensee was reminded that food that is brought from the child's home shall be labeled with the child’s name and properly stored or refrigerated.

LPA conducted a record review of 1 child's record and the Licensee's record. Based on the child's record review, child (C1) did not have the Individual Infant Sleeping Plan (LIC 9227) and verification of the 15 minute physical checks while child is napping available for review.

Based on the Licensee's record review, the Licensee did not have a TB clearance or risk assessment, Mandated Reporter Training Certificate (AB 1207), and Preventative Health and Safety Practices (EMSA-approved) certificate of completion available for review. Licensee has proof of immunization against measles and pertussis. Licensee has a decline declaration statement available for influenza. Licensee has a current Pediatric First Aid and CPR certification (expires January 31, 2023). Licensee was advised that the Mandated Reporter training (AB 1207) must be completed every 2 years and is available at www.mandatedreporterca.com.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

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: CALDERON FAMILY DAY CARE	FACILITY NUMBER: 191609210
	VISIT DATE: 11/04/2022

NARRATIVE

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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 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 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.

LPA provided assistance to the Licensee on how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

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: CALDERON FAMILY DAY CARE	FACILITY NUMBER: 191609210
	VISIT DATE: 11/04/2022

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).

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, Cheryl Calderon.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/04/2022 01:39 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: CALDERON FAMILY DAY CARE	FACILITY NUMBER: 191609210
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2022

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 interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2022
	Plan of Correction
1 2 3 4	Licensee will conduct a Disaster and Fire Drill and submitt documentation for the date and time that the drills were conducted to LPA via e-mail by December 5, 2022.

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: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/04/2022 01:39 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: CALDERON FAMILY DAY CARE	FACILITY NUMBER: 191609210
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. 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 for the Licensee which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2022
	Plan of Correction
1 2 3 4	Licensee will complete the Mandated Reporter Training (AB 1207) and submit proof of completion to LPA via e-mail by December 5, 2022.

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 for the Licensee (TB clearance or risk assessment) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2022
	Plan of Correction
1 2 3 4	Licensee will submit a TB clearance or risk assessment for the Licensee to LPA via e-mail by December 5, 2022.

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: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/04/2022 01:39 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: CALDERON FAMILY DAY CARE	FACILITY NUMBER: 191609210
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 for the Licensee which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2022
	Plan of Correction
1 2 3 4	Licensee will complete the Preventative Health and Safety Practices (EMSA-approved) and submit proof of completion to LPA via e-mail by December 5, 2022.

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. 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 child's record (C1) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2022
	Plan of Correction
1 2 3 4	Licensee will submit the completed Individual Infant Sleeping Plan (LIC 9227) for child (C1) to LPA via e-mail by December 5, 2022.

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: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/04/2022 01:39 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: CALDERON FAMILY DAY CARE	FACILITY NUMBER: 191609210
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 1 child's record (C1) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2022
	Plan of Correction
1 2 3 4	Licensee will submit verification of the 15 minute physical checks for child (C1) napping for at least one week to LPA via e-mail by December 5, 2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC809 (FAS) - (06/04)

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