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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191614561
Report Date: 05/04/2022
Date Signed: 05/05/2022 06:29:44 AM


Document Has Been Signed on 05/05/2022 06:29 AM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:VILLALOBOS, BLANCA FAMILY DAY CAREFACILITY NUMBER:
191614561
ADMINISTRATOR:BLANCA VILLALOBOSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 399-6766
CITY:VENICESTATE: CAZIP CODE:
90291
CAPACITY:12CENSUS: 8DATE:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:BLANCA VILLALOBOSTIME COMPLETED:
12:00 PM
NARRATIVE
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On 5/4/2022 Licensing Program Analysts (LPA), Loyce Phillips conducted an unannounced Annual Required Inspection and was met by Licensee, Blanca Villalobos. LPA observed 8 children in care and 1 assistant. LPA observed 2 addition adults in the home. All adults present have a criminal record clearance. Days and hours of operation are Monday through Friday 7:30am to 5:30pm.

LPA toured the home inside and outside. This is a 2 bedroom 1 bathroom home with living room, kitchen and detached garage that has been converted into the main day care room.

The areas that are accessible to children: Living room, kitchen area, enclosed patio, converted garage with restroom and back yard. Licensee advised the children nap in the living room.

The areas that are off limits to children: Bedrooms #1 #2 that were inaccessible to children by upper locks. The area behind the converted garage is off limits, by children safety gate and fenced in the outdoor area.

No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible to children.

There is a full charged fire extinguisher located next to the enclosed patio. The facility has a working smoke detectors and carbon monoxide detector, inside the home. The facility has adequate heating and ventilation for safety and comfort. There are no stairs in the home. Safe toys and play equipment are observed. Children sleep on mats. The home has working telephone service and LPA confirmed the phone number is (310) 399-6766.

SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: VILLALOBOS, BLANCA FAMILY DAY CARE
FACILITY NUMBER: 191614561
VISIT DATE: 05/04/2022
NARRATIVE
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Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Capacity as specified on the license is being maintained.

Licensee’s Mandated Reporter Training expired on 7/11/2021. Licensee’s pediatric CPR/First Aid expires on 43/15/2022. A review of records indicates that Licensee have immunization records on file for influenza, pertussis and measles.

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 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.

Licensee is caring for infants. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: VILLALOBOS, BLANCA FAMILY DAY CARE
FACILITY NUMBER: 191614561
VISIT DATE: 05/04/2022
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.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page 809 D) Licensee was provided a copy of their appeal rights. Technical advisories were discussed with Licensee.

An exit interview was conducted, a copy of this report was read and provided to the Licensee. This report shall me made available to the public upon request. LIC 9213 Notice of Site Visit was provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/05/2022 06:29 AM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: VILLALOBOS, BLANCA FAMILY DAY CARE
FACILITY NUMBER: 191614561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with Licensee, the licensee did not comply with the section cited above in 1 out of 1, sleeping log was not recorded which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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Licensee agreed to complete sleeping log and keep in the infants file.
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
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Based on record review and interview with Licensee, the licensee did not comply with the section cited above in 2 out of 2 mandeted reporter certificates were not updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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Licensee agreed to complete Mandated Reporter and send Certificate by POC date.

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: Peter FloresTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/05/2022 06:29 AM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: VILLALOBOS, BLANCA FAMILY DAY CARE
FACILITY NUMBER: 191614561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022

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
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 Pediatric CPR/First Aid were expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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Licensee and staff agrees to complete Pediatric CPR/First Aid and send proof of completion to LPA by POC date.
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
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Based on record review and interview statement from LIcensee, the licensee did not comply with the section cited above in 1 out of 1 LIC 9227 forms were not completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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Licensee will place completed LIC 9227 form in infants file by POC date.

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: Peter FloresTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
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