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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407790
Report Date: 05/10/2022
Date Signed: 05/10/2022 01:25:26 PM


Document Has Been Signed on 05/10/2022 01:25 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:VASQUEZ FAMILY CHILD CAREFACILITY NUMBER:
197407790
ADMINISTRATOR:VASQUEZ, LIZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 220-7568
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:14CENSUS: DATE:
05/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Liz VasquezTIME COMPLETED:
01:45 PM
NARRATIVE
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On 05/10/2022 Licensing Program Analyst (LPA) Laticia Thompson observed the following deficiencies during an unannounced complaint investigation

Licensee was unable to provide a roster
Licensee does not have an individual Sleep Plan
C#6 was sleep in an adult bed with pillows around him
Licensee was unable to provide documentation of 15 minute check in for infants
Sharp knife on kitchen counter and in kitchen sink
Poisonous hazardous material under kitchen sink accessible to children
See LIC 809D

An exit interview was conducted with licensee in which a copy of this report along with appeal rights were provided to licensee.

The licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If facility was cited type A violation a copy of the licensing report (LIC809 and 809D) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. Licensee must inform the parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months via form LIC-9224 Acknowledgement of Receipt of Licensing Reports.




SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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Document Has Been Signed on 05/10/2022 01:25 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: VASQUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197407790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2022
Section Cited

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102425 (c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file. This requirement was not met as evidence by
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Based on record review and interview. Licensee was unable to provide form LIC9227, this poses an immediate health and safety risk to children under care.
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Type A
05/10/2022
Section Cited

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102425 (j)The provider shall supervise infants while they are sleeping and adhere to... requirements,,, provider shall physically check on the infant every 15 minutes.. shall check and document the following:(A)Labored breathing.(B)Signs of distress.(D).Documentation... maintained in the infant’s file...This requirement was not met as evidence by
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Based on observation, interview and record review Licensee was not able to provide records of that requirements were being followed, which poses an immediate Health & Safety risk to children in care
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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: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/10/2022 01:25 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: VASQUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197407790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2022
Section Cited

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102417(g)(4) Operation of a Family Child Care Home (g) The home shall be free from defects or conditions which might endanger a child..,(4) Poisons, detergents, cleaning compounds medicines...and other items which could pose a danger... to children shall be stored where they are inaccessible This requirement was not met as evidence by
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Based on LPA's observation of a sharp kinife on the kitchen counter a knife in the sink, hazardous material under kitchen and bathroom sinks were accessible to children which poses an immediate, Health and Safety Risk to children in care.
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Type B
05/10/2022
Section Cited

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102417(g)(8) Operation of a Family Child Care Home. Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met as evidence by
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Based on observation, interview and record review licensee was unable to provide a roster of children that are cared for in the facility, which poses a potential Health, Safety, or Personal Rights Risk to children in care.
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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: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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