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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192008458
Report Date: 06/16/2023
Date Signed: 06/16/2023 05:10:12 PM


Document Has Been Signed on 06/16/2023 05:10 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:JIMENEZ FAMILY CHILD CAREFACILITY NUMBER:
192008458
ADMINISTRATOR:JIMENEZ, ESTHERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 888-2120
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY:14CENSUS: 4DATE:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Licensee Esther JimenezTIME COMPLETED:
05:15 PM
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This inspection was conducted in Spanish

Licensing Program Analyst (LPA) Veronica Martinez Garza conducted an unannounced 1-year required inspection at the above facility on 06/16/23 at 02:35 p.m. A COVID risk assessment was conducted upon entry- appropriate PPE was used. LPA met with Esther Jimenez, Licensee who guided analyst on a tour of the facility. There were 04 children present during this inspection- 1 being an infant. Per licensee, 09 children are enrolled. Present during the inspection was the Licensee’s daughter in law and daughter in law adult son.

Operation hours are Monday – Friday 06:00 a.m. – 06:00 p.m.

This is a one-story home which consists of 2 bedrooms, 2 bathrooms, living room, dining room, kitchen, den (day care room), front yard, back yard (fenced), garage, and storage (converted into a room). Per Licensee, family members residing in the home are 3 adults and 2 minors. All individuals present in the home have obtained a criminal record clearance or exemption prior to working, residing, or volunteering in a licensed home. Individuals living in the home are identified on the attached LIC811.

Areas accessible to children include living room, dining room, 1 bathroom located inside the den, and back yard (fenced) for play. The bathroom children use was observed to be safe and sanitary.

Per licensee, areas off limits to children and parents include 2 bedrooms, 1 bathroom, storage, garage and front yard (fenced). Per Licensee, there are no pets on the premises.

LPA toured all areas identified on the facility sketch used by children during this visit and were inspected for safety, comfort, and cleanliness. LPA observed safe toys, play equipment and materials for children. Napping: LPA observed napping equipment: cots located in the den (day care room).

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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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Document Has Been Signed on 06/16/2023 05:10 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 192008458

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

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 observation and record review, the licensee did not comply with the section cited above in Licensee and assistant do not have an approved Pediatric CPR/FA. Per Licensee, Pediatric CPR/FA was taken online which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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Per Licensee, both her and the assistant will take the Pediatric CPR/FA through an approved vendor (EMSA, American Red Cross, or American Heart Association) and will submit proof to LPA by POC due date.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in assistant is missing proof of Infliuenza vaccine or declination letter and adults #2 and #3 are missing proof of TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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Per Licensee, she will submit proof of Influenza vaccine or declination letter for assistant and TB test clearance for adults #2 and #3 to LPA 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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 192008458
VISIT DATE: 06/16/2023
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 LPA observed that cots do not hinder the entrance or exit to and from the space they are sleeping in. Per licensee, children nap in the den (day care room). LPA observed a bassinet (bedroom #2) and an inclined sleeper (in the living room). LPA consulted with Licensee regarding approved sleeping equipment. Per Licensee, she has a play yard available for infant children and will ensure she has the play yard available to children. Licensee also stated that the inclined sleeper was provided by parent of Child #1 (C1) but that she will return the inclined sleeper today during pick up. The licensee does understand that licensing staff may have access to off-limit areas during inspection visit if necessary.

**Rooms that are off-limits need to be made inaccessible during operating hours**

Per licensee, food is provided to all children in care. There is telephone service via a landline. There is central ventilation and heating.

Detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock.

At 02:45 p.m. combined smoke and carbon monoxide detectors were tested and are operable. The valve on the required 2A10BC fire extinguisher indicates fully charged and was serviced on 06/03/23, as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually.

LPA observed a first aid kit readily available in the den (day care room). Isolation area for sick children waiting to be picked up is in the living room of the home with supervision.

Per Licensee, there are no firearms or weapons stored in the home.

LPA observed the following required posted documentation in the den of the facility: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA reviewed facility records for LIC 9040- Facility Roster, LIC 610- Emergency Disaster Plan and Disaster drill log. All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Last drill documented was 06/09/23. Children's roster was reviewed and is current.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 192008458
VISIT DATE: 06/16/2023
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Currently children use the back yard for outdoor play with adequate shade and age-appropriate play equipment for children in care. LPA did not observe any objects that could be hazardous to children in care. Licensee understands that children should be supervised at all times.

LPA did not observe any pools, spas, hot tubs, fishponds, or similar bodies of water during the inspection.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

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, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months). LPA observed C1 was missing proof of 15-minute sleep check, C2 is missing immunizations and LIC 627 is incomplete.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, expires 02/2025. LPA observed that the Pediatric CPR/FA taken by the licensee and assistant are not EMSA, American Heart Association or American Red Cross approved. Per Licensee, Pediatric CPR/FA was taken online. LPA Proof of immunizations against measles, pertussis and TB clearance or risk assessment was on file for Licensee and assistant. LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate are on file for Licensee. Licensee's mandated reporter training expires 05/12/24. LPA observed assistant is missing proof of Influenza vaccine or declination letter, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse. LPA also observed adults #2 and #3 are missing proof of TB clearance or risk assessment.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018, any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers

The licensee is operating within proper capacity and ratios. LPA observed licensee to be present at the home and providing adequate care and supervision.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 192008458
VISIT DATE: 06/16/2023
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Currently licensee does care for infants. 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. LPA provided PIN 20-24-CCP SP, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months), and PUB 217 Never Shake a Baby Brochure. LPA provided consultation on LIC 9227 and 15-minute documentation.

No infant walkers, No baby bouncers, No Johnny jumpers, No exersaucers and any other item that falls into that category.

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

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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 192008458
VISIT DATE: 06/16/2023
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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

LPA advised the licensee to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

The following deficiencies were cited in accordance with Title 22 of the California Code of Regulations and Health & Safety Codes. Please see 809D for documentation of deficiencies.

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 Licensee Esther Jimenez and provided Appeal Rights.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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