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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198002693
Report Date: 07/29/2022
Date Signed: 07/29/2022 03:23:57 PM


Document Has Been Signed on 07/29/2022 03:23 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:PENA FAMILY DAY CAREFACILITY NUMBER:
198002693
ADMINISTRATOR:PENA, IDALIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 222-2416
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY:14CENSUS: 8DATE:
07/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Idalia Pena TIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst's (LPA's) Carolyn Tuba and Judy Mora conducted an unannounced Case Management inspection on this day. At approximately 9:00 AM, Licensing staff were greeted at the door by a male; LPA Carolyn Tuba introduced herself and asked for the Licensee. The male asked licensing staff to hold on and closed the door. Licensee, Idalia Pena, then came to the door. LPA Carolyn Tuba introduced licensing staff and explained the purpose of the inspection. The Licensee is Spanish speaking. Licensing staff observed 4 children in care at the time. Licensee was asked for the name of the man who opened the front door, Licensee indicated that it is her uncle and his name is Juan Francisco Montes, who does not have a criminal record clearance on file. Per Licensee, he has been living in the home for approximately one year. Mr. Montes left out the backdoor and into the neighbor's back yard as Licensing staff walked into the home. Per Licensee, the neighbor's house is her sister's house.

Per Licensee there are 3 adults living in the home, herself, her uncle and her husband. Licensee then guided licensing staff on a tour of the entire facility including all off limit areas. During this inspection, Licensing staff observed the Licensee's husband, Osmin Pena, in one of the bedrooms (criminal record clearance on file). Licensee then indicated that her 2 adult sons, Osmin Pena Jr. and Sergio Pena, were present in one of the other bedrooms, (criminal record clearances are not on file). The individuals were observed to be asleep. Licensee then indicated that they are living in the home and have always been in and out of the home. Licensing staff continued tour with Licensee, and observed that the garage has been converted into a living space. LPA Carolyn Tuba observed an adult, Roxana Salinas Deras (criminal record clearance not on file) and 1 minor present in living area. Per Ms. Salinas Deras, she has been living in the home since the beginning of 2022.

*REPORT CONTINUES ON NEXT PAGE
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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 07/29/2022 03:23 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: PENA FAMILY DAY CARE
FACILITY NUMBER: 198002693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2022
Section Cited

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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:Obtain a California clearance or a criminal record exemption as required by the Department
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This requirement was not met as evidenced by review of criminal record clearances on file and the adults observed living and present in the home at the time of inspection on 07/29/22. The followings adults living in the home do not have a criminal crecord clearance: Juan Francisco Montes, Miguel Angel Monge, Christian Alexander Monge and Roxana Salinas. This is an immediate risk to the health and safety of children in care. An immediate civil penalty in the amount of $2000.00 is being issued on this date.
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Type A
08/01/2022
Section Cited

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Operation of a Family Child Care Home
The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: Fireplaces and open-face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector
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device which meet standards established by the State Fire Marshal.
This requirement was not met as evidenced by licensing staff observation of the fire extinguisher present and Licensee's declaration. The fire extinguisher was observed to not be fully charged and Licensee indicated that she has had it for 2 years and has not serviced it. This is an immediate risk to the health and safety of 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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2022 03:23 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: PENA FAMILY DAY CARE
FACILITY NUMBER: 198002693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2022
Section Cited

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Personnel Requirements
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 was not met as evidenced by Licensee file review. The Licensee does not
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have a current Pediatric First Aid & CPR certification, expired 01/19/21. This is a potential risk to the health and safey of 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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


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: PENA FAMILY DAY CARE
FACILITY NUMBER: 198002693
VISIT DATE: 07/29/2022
NARRATIVE
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At this time, 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 is going to be assessed due to this regulation being violated. A total of $2000.00 civil penalty is being assessed on this day.

During this inspection, at approximately 10:02 AM LPA Mora observed that the required 2A10BC fire extinguisher is not fully charged. Per Licensee, she has had it for 2 years and has not had it serviced. Licensee was reminded that the fire extinguisher needs to be serviced yearly as required; this is an immediate risk to the health and safety of children in care. Smoke and carbon monoxide detectors were tested and are operable. Licensing staff requested a current roster from the Licensee. Licensee indicated that she did not have one. A Child Care Facility Roster (LIC 9040) was provided to the Licensee to be completed during this inspection. Licensee was advised to provide the names of all children currently enrolled and all children who were dis-enrolled within the last few months, totaling to 14 children. LPA Mora also observed that the Licensee does not have a current Pediatric First Aid & CPR certification, which expired 01/19/21; this is a potential risk to the health and safety of children in care.

Licensee's assistant/sister, Silvia Hagemoussa, arrived during this inspection. Four additional children arrived during this inspection.

At 11:29 AM, Licensee disclosed to licensing staff that the 2 males in the bedroom are not her son's. Licensee indicated that she is renting the room to her nephews. Licensing staff asked Licensee to have them come out and to provide identification. The individuals residing in one of the bedrooms of the home are, Miguel Angel Monge Serrano and Christian Alexander Monge Serrano (criminal record clearances are not on file). Photos were taken of each individual's identification of those who do not have a criminal record clearance on file.

Licensing staff informed licensee, Idalia Pena, that this report dated 07/29/22 document(s) 2 Type A citations which shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.

*REPORT CONTINUES ON NEXT PAGE

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: PENA FAMILY DAY CARE
FACILITY NUMBER: 198002693
VISIT DATE: 07/29/2022
NARRATIVE
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Also, licensing staff informed the licensee, Idalia Pena, to provide a copy of this licensing report dated 07/29/22 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. LIC 9224 was provided to the Licensee.

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 the Licensee, Idalia Pena. Appeal rights explained & provided.

*END OF REPORT

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
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