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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192007750
Report Date: 07/13/2022
Date Signed: 07/13/2022 12:30:09 PM


Document Has Been Signed on 07/13/2022 12:30 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:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
192007750
ADMINISTRATOR:PEREZ, NOEMIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 421-0129
CITY:HAWAIIAN GARDENSSTATE: CAZIP CODE:
90716
CAPACITY:14CENSUS: 5DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Noemi Perez, LicenseeTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) Alicia Mooberry and Austin Estrada conducted a Required Annual Inspection on this date. LPA met with Noemi Perez, Licensee and provided the inspection Entrance Checklist, LIC 126. Licensee provided tour of facility. LPA inspected rooms/areas on the facility sketch in which child-care services are provided and to which children have access. Per licensee the hours of operation are Sunday-Monday 7:00am-6:00pm. There were 5 children present. Also present was Alejandra Perez, Licensee's daughter and assistant. All adults present have obtained the required Background Clearance. Individuals residing in the home were discussed and noted.

This is a one story home which consists of 3 bedrooms, 2 bathroom, kitchen, dining area, living room, laudry room, garage/playroom and backyard.


Per licensee, areas off limits to children and parents include: 2 bedrooms, 1 bathroom, storage room in garage, storage shed in the back.
The main childcare areas are the enclosed patio/laundry room and garage/playroom in the rear of home. Other areas accessible to children are the living room, kitchen, 1 bedroom used for napping children and bathroom in the hallway.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:



LPA observed required posted documentation in facility entrance which included: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA observed completed facility records including; LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged and was serviced 10/2020, Licensee was reminded that fire extinguisher needs to be serviced yearly. Page 1 – Report Continues

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 192007750
VISIT DATE: 07/13/2022
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The home maintains telephone service via lan line and cell phone. The home is observed to be clean and orderly. There are toys and other age appropriate material available for children. LPA observed that detergents, cleaning compounds and knives are in the kitchen inaccessible to children in overhead cabinets.. 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 living room, away from the other children. Per Licensee there are no firearms or weapons stored in the home.

The bathroom that children use is located in the observed to be clean and free of hazards.

Infant Care: Per licensee and facility roster, there are no infants under 24months currently enrolled. LPA informed licensee of the new Safe sleep regulations and provided PIN 20-24-CCP, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months. Licensee states they will have infants sleep in the living room where they will be supervised at all times.

Currently, children are using the back yard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that could be hazardous to children in care. LPA observed a storage shed that is ket locked with padlock.



Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, and documentation of 15-minute Infant Sleep Check (0-24 months)
LPAs observed that Child #4 and #5 did not have facility files and Child #2 was missing immunization records which poses a potential risk to the health and safety of children in care.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations 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.

LPA observed that licensee is implementing COVID-19 precautions and procedures and observed to be wearing a face mask.

-------------------Page 2 – Report Continues

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 192007750
VISIT DATE: 07/13/2022
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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.

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

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.

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.

Based on the LPA's observations and records review the following deficiencies will be cited today in accordance with California Title 22 Regulations.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Noemi Perez. Appeal Rights were discussed and a copy provided.

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/13/2022 12:30 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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 192007750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
102421 Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
(1) The licensee shall keep the signed and dated notice form for at least three years following termination of service to the child.
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7).

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 5 children's were missing the required documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2022
Plan of Correction
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Per licensee, they will complete the children's file and send a copy to LPA via email by POC Due date
Type B
Section Cited
CCR
102418(a)

102418 Immunizations

(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 1 out of 5 children do not have a record of immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2022
Plan of Correction
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Per Licensee, they will provide proof of Immunization to LPA via email by POC due 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: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4