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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409258
Report Date: 05/24/2022
Date Signed: 05/24/2022 02:11:54 PM


Document Has Been Signed on 05/24/2022 02:11 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
197409258
ADMINISTRATOR:PEREZ, ESTHERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 264-4016
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:14CENSUS: 0DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Esther PerezTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady King-Lewis conducted an Required 1 Year Inspection at the above facility. Upon arrival LPA was greeted by licensee, Esther Perez. LPA was informed licensee was injured in April and have not cared for children for the last 2 months. Licensee stated she doing better and is now ready to care for children. The day care take place in the following area of the home: bonus room, patio bathroom, and rear yard. No body of water on the premises.

Licensee states the day care hours of operation is less than 24 hours 7 days a week. Currently living in the home are licensee, and licensee’s spouse.

During the inspection LPA observed the facility Physical Plant, Care and Supervision, Facility Records Review, and Facility Administration.



LPA discussed safe sleep; informed licensee to refer to regulation 102425(J) for documentation requirement. LPA reviewed requirement with licensee during this inspection. Licensee shall supervise infants while they are sleeping by physically checking every 15 minutes and documenting the child status in writing. Licensee was informed all infants shall have an individual infant Sleeping Plan (LIC 9227). Licensee aware no infant shall be swaddle, car seat shall not be used for sleeping, LPA provided Child Care Licensing Safe Sleep web page as an additional resource:www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 05/24/2022 02:11 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

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
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Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Licensee shall complete the mandated reporter training by POC date. Training to be conducted every 2 years at www.mandatedreporterca.com
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on ecord review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Licensee read immunizations section code 101418(g) and proved LPA a written statement stating she understand the regulation.

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: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2022 02:11 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Licensee shall provide LPA a written statement stating she understand a current roster shall be available and maintain for 3 years.
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Licensee shall provide LPA a written statement stating she understand a current roster shall be available and maintain for 3 years.

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: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258
VISIT DATE: 05/24/2022
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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. To provide Incidental Medical Services, such as administering blood glucose monitoring, inhaled medications, Epi-pen and Epi-pen Jr., insulin shots, gastrostomy tube feeding and care, or carrying out other medical orders, it is best practice to complete a “Plan for Providing Incidental Medical Services”. This plan will help you ensure that you can provide this service in the safest manner possible. A Plan for Providing IMS must be submitted to the Department.

Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in writing within 7 day of incident on the form LIC624B per the regulation. The report unusual incident/injuries report should be emailed to UnusualIncidentReport@dss.ca.gov

During this inspection facility was observed not to be in compliance with Title 22. Please see LIC 809D for deficiencies.

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.

Exit interview conducted and report was reviewed with the licensee a copy of this report and a notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4