197494753-6-9-2021-30-CC-LCAS-C3TVKY-20210609163106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494753
Report Date: 06/08/2021
Date Signed: 06/09/2021 04:31:37 PM

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:	MARTINEZ GONZALEZ & SANTACRUZ FAMILY CHLD CARE		FACILITY NUMBER:	197494753
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	06/08/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Abigail Martinez Gonzalez		TIME COMPLETED:	04:45 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 6/08/21 at 3:33 pm, Licensing Program Analyst (LPA) Lourdes Castellanos conducted an announced Pre-Licensing tele-inspection with applicant Abigail Martinez Gonzalez via FaceTime due to the current public health crisis (COVID-19). Applicant is applying for a Small Family Child Care License to operate Monday Through Friday 7:30 am -5:30 pm (Capacity 8) The applicant guided the LPA on a virtual tour of the home (inside/outside). LPA did not observe any children present. The home is clean, orderly, and comfortable. All adults in the home have been fingerprinted and associated to the facility. Areas identified on the facility sketch were inspected. This is a single-story home with 2-bedrooms, 1 bathroom, a living room, dining area, kitchen and laundry area and garage located in back which is used as an activity room. Entry into the home will be thought the main front door. At the entryway LPA observed a shoe rack, cubbies, and a parent board with required documents: Emergency Disaster Plan, Earthquake Preparedness Checklist, Notification of Parents Rights Poster. The primary childcare rooms are the living room and dining room. LPA observed age-appropriate tables/chairs, toys, and educational items. There is a fireplace with a screen that has a child safety lock to make it inaccessible to the children. Bedroom #1 will be used as the insulated room LPA observed a small couch, age-appropriate toys, bookshelf and cots that will be kept in the storage room. The off limited room is bedroom #2 which is made inaccessible by closed door with safety doorknob cover. The bathroom that children will use is shared by both rooms, the door that leads to the off-limits bedroom is made inaccessible with child safety door knob cover. LPA advised licensee that while operating childcare she had to maintain the door to bedroom#2 locked. Page 1 of 6

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lourdes Castellanos	TELEPHONE: (424) 301-3066
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: MARTINEZ GONZALEZ & SANTACRUZ FAMILY CHLD CARE	FACILITY NUMBER: 197494753
	VISIT DATE: 06/08/2021

NARRATIVE

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The bathroom was inspected, LPA observed bathroom to be clean, free of hazardous items and cabinets had safety latches a poster for guidance effective hand washing procedures were observed. There are two fully equipped 2A10BC fire extinguishers located in the entryway and the kitchen. The kitchen area was inspected LPA observed kitchen cabinets having safety latches, the stove has child protected safety knobs and knives and sharp objects were inaccessible to children. Smoke and carbon monoxide detectors were observed and tested during inspection. First aid kit was observed.

Children in care will access the back yard through the kitchen. The outdoor area was inspected. There are no bodies of water on the premise. The outdoor area provided adequate shade, padding, and age-appropriate equipment (toys, tables and chairs.) The backyard area is gated. The cemented patio area was observed to have a patio table and chairs. LPA observed Trashcans which are made inaccessible to children.

The garage will be used as an activity room for children. LPA observed age appropriate furniture (children table/chairs,) arts & crafts supplies, shelves with toys, paint supplies, and other educational items. LPA advised the licensee that no eating, sleeping can be conducted in this area.
LPA advised the licensee that when the children are using the outdoor playroom to ensure it is cooled and heated properly. LPA advised licensee to clean, disinfect toys after each use.

The following was thoroughly discussed with the licensee:

Applicant was made aware that once licensed, it is the licensee’s responsibility to know the regulations as well as anyone who assists in providing care. Applicant was advised on how to access quarterly reports, forms, and regulations for Child Care online at www.ccld.ca.gov. Applicant was also encouraged to read the Child Care quarterly updates to remain informed of any changes or updates to the Regulations.

Applicant was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact

information is as follows: Phone Number (916) 654-1541 and Email Address: childcareadvocatesprogram@dss.ca.gov

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SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lourdes Castellanos	TELEPHONE: (424) 301-3066
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: MARTINEZ GONZALEZ & SANTACRUZ FAMILY CHLD CARE	FACILITY NUMBER: 197494753
	VISIT DATE: 06/08/2021

NARRATIVE

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Applicant agrees to operate the family child care home in a way to reflect a home-like environment and agrees to the following per Children’s Personal Rights Title 22 Regulation(s): 102423 (a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (1) To be treated with dignity in his/her personal relationship with staff and other persons. (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. (3) To have parents or guardians informed by the licensee of the provisions of the law regarding complaints and the procedures for registering complaints confidentially, including, but not limited to the address and telephone number of the licensing agency's complaint unit. (4) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning.

Applicant was reminded of their responsibility to report suspected child abuse. Mandated Reporter Training is required and needs to be renewed every 2 years.

Mandatory Forms for the children’s files and provider’s files were discussed. Applicant was referred to LIC 311D: Records To Be Maintained At The Facility - Family Child Care Home..

If cited for a Type A Deficiency, the Notice of Site Visit must be posted at the entrance of the facility along with a copy of the licensing report (LIC809 or LIC9099) for 30 days. If these requirements are not met, civil penalties in the amount of $500 per violation will be assessed. The applicant was made aware that a licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment.

The applicant has been informed that all employees and adults in the home must be associated to the facility. If the licensee fails to have proof of a fingerprint clearance or fails to associate a previously cleared individual to the facility, a civil penalty of $500.00, per day the person has been present, will be assessed. The first violation is subject to the penalty for up to five days. If there is a subsequent violation in a 12-month period, the fine will continue for up to 30 days.

The "Notification of Parent's Rights" (PUB394) was discussed with the licensee and the licensee was advised that it must be posted in an area of the home accessible to parents.

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SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lourdes Castellanos	TELEPHONE: (424) 301-3066
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: MARTINEZ GONZALEZ & SANTACRUZ FAMILY CHLD CARE	FACILITY NUMBER: 197494753
	VISIT DATE: 06/08/2021

NARRATIVE

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Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the visit.

Zero Tolerance Related Regulations from Family Child Care Homes were also discussed. This includes the following: Absence of Supervision: including, but not limited to, a child left unattended, a child left alone with a person under 18 years of age, and lack of supervision resulting in a child wandering away. (HSC 1597.58(c)(2)). Regulation(s): 102417(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. Civil penalty applies when a child is left unattended. Absence of Supervision: including, but not limited to, a child left unattended, a child left alone with a person under 18 years of age, and lack of supervision resulting in a child wandering away. (HSC 1597.58(c)(2)). Regulation(s): 102417(k)(1) Children shall not be left in parked vehicles. Civil penalty applies when a child is left unattended in a parked vehicle.

At this time, the facility does not provide Incidental Medical Services - IMS. 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. Incidental Medical Services Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering EpiPen Jr. and EpiPen or other Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Carrying out medical orders when the child’s physician has determined that a layperson can be trained and safely carry out the orders.

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.

Immunization records are to be obtained from parent's prior to a child being left with provider. Immunization records shall be kept on blue cards from the local health department. Title 22 Regulations, Child Care Quarter Updates may be viewed at www.ccld.ca.gov.

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SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lourdes Castellanos	TELEPHONE: (424) 301-3066
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC809 (FAS) - (06/04)

Page: 4 of 6

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: MARTINEZ GONZALEZ & SANTACRUZ FAMILY CHLD CARE	FACILITY NUMBER: 197494753
	VISIT DATE: 06/08/2021

NARRATIVE

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The applicant will provide the following forms to the parents prior to enrollment: LIC 627 (Emergency Consent), LIC 700 (ID & Emergency), LIC 702 (Health History), LIC 613A (Personal Rights), LIC 995A (Parent's Rights), LIC 995E (Important Information for Parents), LIC 282 (Affidavit Liability Insurance). Immunization records are to be obtained from parent's prior to a child being left with provider. Immunization records shall be kept on blue cards from the local health department. Title 22 Regulations, Child Care Quarterly updates and additional information may be obtained at the department's website www.ccld.ca.gov

LPA discussed discipline policies, personal rights, civil penalties and appeal rights. LPAs informed applicant of regulations regarding reporting unusual incidents and injuries within 24 hours.

Applicant was informed that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome). The applicant was provided a handout on Safe Sleep. No smoking is allowed on a day care premises. Never shake a baby to prevent Shaken Baby Syndrome. Only children eating may be in high chairs. Applicant was notified that it is required to wash hands after every diaper change. Page 5 of 7

FORMS TO BE POSTED

· LIC203 Facility License
· LIC 610A Emergency Disaster Plan
· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster
COVID-19 related flyers and best practices

Children’s records requirements:

· LIC 700 Identification and Emergency Information
· LIC 627 Consent for Emergency Medical Treatment
· LIC 282 Affidavit Regarding Liability Insurance
· LIC 9150 Parent Notification Additional Children in Care
· Immunization record
· PUB 72- Family Child Care Consumer Guide
· LIC 995A Notification of Parent’s Rights

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SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lourdes Castellanos	TELEPHONE: (424) 301-3066
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: MARTINEZ GONZALEZ & SANTACRUZ FAMILY CHLD CARE	FACILITY NUMBER: 197494753
	VISIT DATE: 06/08/2021

NARRATIVE

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FACILITY RECORDS:
· LIC 624B Unusual Incident/Injury Report
· LIC 9040 Child Care Facility Roster
· LIC 9052 Employee Rights,
· LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
· LIC 9149 Landlord Consent Form, if you plan to care for more than 6 children for a Small
· LIC 9151 Property Owner/Landlord Notification Form
· Proof of current pediatric CPR and First Aid Certificates
· Copy of your deed or lease/rental agreement
· Documentation of Fire and Disaster drills
· Proof of immunization's against pertussis (TDAP), measles (MMR), and influenza
· Mandated Reporter certificate – www.mandatedreporterca.com – renewed every two years.

Applicant was provided a Self-Assessment guide to follow in response to COVID-19 and was also informed that during today’s inspection that Licensing Program Analyst, Castellanos will provide Technical Assistance in response to reducing the spread of COVID-19. Applicant was provided the following COVID-19 resources to refer to when in operation:

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN_20-02-CCP.pdf

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN_20-04-CCP.pdf

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN%2020-19-CCP.pdf

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN-20-11-CCP.pdf

https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-childcare.html

Home is Ready for licensure for a Small Family child care home with a capacity of 8 children in care.

An Exit Interview was conducted, and a copy of this report was emailed to the applicant. It has been explained that a reply to the email shall be considered a substitute for the hard-copy signature.

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lourdes Castellanos	TELEPHONE: (424) 301-3066
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC809 (FAS) - (06/04)

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