197414307-4-18-2024-12-CC-CHEH-D4FRVN-20240418132149

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197414307
Report Date: 04/18/2024
Date Signed: 04/18/2024 01:22:19 PM

Document Has Been Signed on 04/18/2024 01:22 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:	MENENDEZ FAMILY CHILD CARE		FACILITY NUMBER:	197414307
ADMINISTRATOR:	MENENDEZ, MARIA A.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 992-1224
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	14	CENSUS: 9	DATE:	04/18/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Maria Menendez		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/18/2024, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required annual inspection at the Menendez Family Child Care. Upon arrival, the LPA met with the licensee, Maria Menendez, who guided the LPA on a facility tour. Individuals that reside in the home include 6 adults (licensee and 5 adult friends) and no minor children. During this inspection, 9 childcare children and 2 assistants were present. Per the licensee, the hours of operation are Monday to Sunday for less than 24 hours. Incidental Medical Services (IMS) were discussed. Per the licensee, she does not have children who need IMS. The home is set up as follows: This is a two story,5 bedrooms, 3 bathrooms home with a kitchen, living room, formal dining room, laundry room, family room, and garage. The home was inspected for safety, comfort, cleanliness, telephone service, central air, and heat and ventilation. The house has central heating and air conditioning. All windows have screens free of cracks, bugs, and debris. Main Area: Main care is provided in the living room, family room, classroom area near the front entrance, and playroom/game room—garage (has a permit). Children use the bathroom in the hallway on the right near the classroom area. They have access to the kitchen and outdoor area. Off-limit areas include all bedrooms, the entire upstairs (barricaded by a safety gate), bathrooms #2 and #3 (upstairs), and the laundry room (upstairs).

SUPERVISOR'S NAME: Claretta Yates	TELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol Heath	TELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MENENDEZ FAMILY CHILD CARE	FACILITY NUMBER: 197414307
	VISIT DATE: 04/18/2024

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Living room, family room, classroom area near the front entrance, and playroom/game room- garage (has a permit): LPA observed age-appropriate toys and furniture for the children in the designated childcare areas. Several plastic storage bins were observed in which games and toys are stored for the children. There are games and books on the premises of this facility. There are mats on the floor with educational/learning activities. The mats were observed to be in good condition. A TV plays educational videos for children, and an adult-size couch. In the family room, additional toys were observed to be stored in cubbies.
Children's bathroom (#1): The Children will use the bathroom down the hallway to the right. The bathroom was toured and inspected, and the sink/toilet is in operable condition. Toilet and faucets are clean, safe, and operable. LPA reminded All poison and medications are inaccessible to children with child safety latches on the sink cabinet. The shower/tub is free of hazards (childcare bathroom). LPA observed cleaning supplies in the children bathroom and personal items in the children's bathroom. The toilet and faucet are clean and operable. Cleaning supplies are safely latched under the bathroom sink.
Kitchen/Dining Room: The kitchen was inspected to ensure hazardous and dangerous items were inaccessible to children (Safety latches). LPA reminded the licensee, sharp utensils, poisons, and medications need to make them inaccessible to children in the kitchen, with safety latches on cabinet doors and drawers. Cleaning supplies are under the kitchen sink.
Backyard: The backyard was inspected; The children use the outside backyard for outside play. The backyard is completely fenced (with block cement). There is no body of water. There is an outdoor air conditioner inaccessible to children with a barricaded fence on the side of the home. LPA observed age-appropriate toys, play equipment, and turf for outdoor play. LPA observed several broken toys outside and the sand box area will need to clean. The licensee signed the declaration. The children will not go outside until the sand box area is clean.

SUPERVISOR'S NAME: Claretta Yates	TELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol Heath	TELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MENENDEZ FAMILY CHILD CARE	FACILITY NUMBER: 197414307
	VISIT DATE: 04/18/2024

NARRATIVE

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Others:
AC/Heating Unit was observed. Two outdoor air conditioners with barricaded gates are inaccessible to children.
Bodies of water: Per the licensee, there are no bodies of water in the home.
Electrical outlets: All unused electrical outlets are plugged in and made inaccessible to children. During the inspection, LPA reminded the licensee to plug all the unused outlets.
Fire extinguisher (2A10BC): LPA observed a required fire extinguisher (2A10BC) reading in Green, located in the kitchen, and inaccessible to children. It meets standards established by the State Fire Marshall.
Fireplace: In the family room, a fireplace was observed that was properly screened via mirror glass doors. The fireplace is inaccessible to children.
Hanging window blind cords: LPA asked the licensee to fix all the window cords to make sure they are inaccessible to children.
Isolation area (Illness): Per the licensee, if the child shows signs of illness, they will be separated from other children and stay in game room
Medications and cleaning solutions: Detergents and cleaning compounds are in the upper kitchen cabinet, and medications are in the off-limits bedroom.
Napping: Children will nap in the designated nap areas with adult supervision. LPA observed 24 mats in the closet.
Overnight Care: According to the licensee, it does not provide overnight care.
Pets: No pet
Phone service: There is a working landline and cell phone
Smoke Detectors and Carbon Monoxide: The smoke detectors and carbon monoxide devices tested operable.
Stairs (For two-story hours): A safety gate is barricaded to make the stairs inaccessible to the children.

SUPERVISOR'S NAME: Claretta Yates	TELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol Heath	TELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MENENDEZ FAMILY CHILD CARE	FACILITY NUMBER: 197414307
	VISIT DATE: 04/18/2024

NARRATIVE

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The first aid kit is in the key-locked closet and is inaccessible to children. The First Aid Kit was observed to be complete with supplies and No a first aid manual.
Transportation: The licensee does provide transportation for children. The licensee has a valid California driver's license, valid vehicle insurance, and vehicle registration.
Weapons or Firearms: Per the licensee, there are No Firearms at the facility at this time. LPA does not observe any firearms.
Documentation:
Child files: LPA reviewed 8 children's records. The records are incomplete and missing forms.
Infant Sleeping Plan (LIC 9227) and Sleeping Log: There are 3 infants enrolled in the facility. The licensee does not have LIC 9227 and Sleeping log. The licensee was unable to find those children’s files. LPA shared the Safe Sleeping Regulation with the licensee.
Staff Personnel File: During an annual inspection, LPA observed 2 staff information. LPA observed LIC 508, 9052, IZ, TB test, LIC 9108, and CPR/First Aid certificates.
Immunization: The licensee and her assistants have the required immunizations (MMR and DTaP). The licensee and her assistants provided a written statement declining the influenza vaccination.
Criminal Record: Per Guardian, all adults who live in this facility obtain a criminal record clearance.
CPR/First Aid: LPA observed that the licensee has current Pediatric CPR and First Aid Training with an expiration date (of 07/24) 1 hour of nutrition training and (8) hours of Preventive Health and Safety Training.
Mandated Reporter Training: The licensee and her assistant was unable to provide their training certifications.

SUPERVISOR'S NAME: Claretta Yates	TELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol Heath	TELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MENENDEZ FAMILY CHILD CARE	FACILITY NUMBER: 197414307
	VISIT DATE: 04/18/2024

NARRATIVE

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Facility fees: Per the Licensing Information System, annual facility fees were current.
Fire Drill and Disaster Drill: Per the licensee, fire and disaster drills are conducted every 6 months; the last drill was documented and conducted on 04/01/2024.
LPA observed that the licensee (does not) have posted the facility license, emergency disaster plan, earthquake preparedness, and parents' rights poster as required.
The following information was discussed with the licensee:
o A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code sections 1596.848(b) and (c). State law prohibits baby walkers, bouncy seats, exersaucer, and other items that fall into that category.
o Capacity requirements, Roster requirements, Posting requirements, and Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children's and provider's files and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. The licensee was reminded that supervision is always required for children in care.
o The licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B
o Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates on courses and updates/changes to the regulations. The licensee was made aware that it is their responsibility to know the regulations, as well as that of anyone who assists in providing care. The licensee was advised that the inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility's phone number; if the phone number is changed, licensing must be notified.
o Mandatory Forms for the children's files and provider's files.

SUPERVISOR'S NAME: Claretta Yates	TELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol Heath	TELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MENENDEZ FAMILY CHILD CARE	FACILITY NUMBER: 197414307
	VISIT DATE: 04/18/2024

NARRATIVE

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o Our Quarterly updates come out every 3 months. They are also now in Spanish. Please log in to the CCLD website, or you can email our advocates to have the quarterly updates sent directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
o Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
o Requirements for fire drills, earthquake drills, and documentation for both.
o The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 a.m. - 5:00 p.m.
o The licensee is reminded that 100% supervision is required for children at all times.
o The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hotline at 1-800-540-4000. Also, call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).
o The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family childcare home where children are present (24/7 ban).
· Family Child Care Homes Licensee [or facility representative] was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

SUPERVISOR'S NAME: Claretta Yates	TELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol Heath	TELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MENENDEZ FAMILY CHILD CARE	FACILITY NUMBER: 197414307
	VISIT DATE: 04/18/2024

NARRATIVE

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· Family Child Care Homes IF THERE IS NO CHILD AT THE FACILITY THAT CURRENTLY NEEDS IMS, USE AS FOLLOWS: Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.
· Centers and Family Child Care Homes Licensee [or facility representative] was informed of the MyChildCarePlan.org website, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
· Family Child Care Homes During the exit interview, the LICENSEE ****, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
· Family Child Care Homes A notice of site visit was given and must remain posted for 30 days.
· To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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-carelicensing/ inspection-process.
Deficiencies cited: (See LIC 809D). The following Type B deficiencies are being cited in accordance with Title 22 of the California Code of Regulations and/or Health & Safety codes.
An exit interview was conducted, and the report was reviewed with the licensee, .
Maria Menendez.

SUPERVISOR'S NAME: Claretta Yates	TELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol Heath	TELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

Page: 7 of 11

Document Has Been Signed on 04/18/2024 01:22 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: MENENDEZ FAMILY CHILD CARE	FACILITY NUMBER: 197414307
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed broen toys outside, the unused plugs did not cover, cleaning supplies and personal materials accessible to the children, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2024
	Plan of Correction
1 2 3 4	The licensee will clean the areas and text LPA the pictures.

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
1 2 3 4	Based on observation,record review, the licensee did not comply with the section cited above. The licensee was unable to provide the sleeping log for 3 infants, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	The licensee will have meeting with the assistants to make sure they understand to document the log every 10-15. The licensee will text or email the log to the LPA.

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: Claretta Yates	TELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol Heath	TELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

Page: 8 of 11

Document Has Been Signed on 04/18/2024 01:22 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: MENENDEZ FAMILY CHILD CARE	FACILITY NUMBER: 197414307
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above, The licensee was unable to provide the training certification, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/22/2024
	Plan of Correction
1 2 3 4	The licensee will email the training certifications to LPA by 4/22/2024

Type B

Section Cited

CCR

102421(a)

Child's Records

(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above, The licensee was unable to provide 3 infants' information (All state require documentations), which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/24/2024
	Plan of Correction
1 2 3 4	The licensee will follow up with parents and email LPA all the paperwork by 4/24/2024.

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: Claretta Yates	TELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol Heath	TELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

Page: 9 of 11

Document Has Been Signed on 04/18/2024 01:22 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: MENENDEZ FAMILY CHILD CARE	FACILITY NUMBER: 197414307
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. The licensee did not update her facility roster, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/22/2024
	Plan of Correction
1 2 3 4	The licensee agreed to update her facility roster and email LPA a copy

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. The licensee was unable to provide LIC 9227 for the 3 infants, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/22/2024
	Plan of Correction
1 2 3 4	The licensee will ask parents to fill out the LIC 9227 and email to LPA by 4/22/2024

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: Claretta Yates	TELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol Heath	TELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

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