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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198002693
Report Date: 03/28/2023
Date Signed: 03/28/2023 07:08:20 PM

Document Has Been Signed on 03/28/2023 07:08 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: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
03/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Idalia PenaTIME COMPLETED:
07:15 PM
NARRATIVE
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Visit Conducted in Spanish

On 3/28/2023 at 2:00 pm, Licensing Program Analyst (LPA) Carolyn Tuba conducted an unannounced required inspection. A Covid-19 risk assessment was conducted prior to entering the facility. LPA met with Licensee, Idalia Pena, during today’s inspection. There was a census of 11 children present, along with Licensee’s assistant. During the inspection visit there was additional adult that lives in the home but was not part of the care of children.

The children's roster was available for review. Fire and earthquake drill log was not available during today’s inspection. Per Licensee 15-minute infant sleep log has not been conducted and LPA provided a sample to for her to use.

This is a one-story single-family home which consists of a converted den at the rear of the home that has been converted for the care and supervision of children, one half bathroom located in day care area (den), and back yard.
Areas off limits include: The whole home consisting of kitchen, dining, living room, four bedroom, two bathrooms, front yard, and attached garage. Kitchen, dining and living room are accessible through passing to reach rear den.
Rooms that are off-limits need to be made inaccessible during operating hours.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. Family members residing in the home are 6 adults (criminal record clearances on file) and 1 minor. There is a working telephone maintained in the home. There are no pets on the premises. Detergents, cleaning compounds, medications, and other items, which can pose a danger to children are inaccessible. Per Licensee poisons and cleaning compounds are kept in cabinet under the kitchen sink, which is locked with a key.
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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2023
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 6
Document Has Been Signed on 03/28/2023 07:08 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 03/28/2023 at 06:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in blankets Blankets, pillows and toys found in play yard where infant sleeps, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2023
Plan of Correction
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LPA consulted with Licensee regarding Safe Sleep
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/28/2023 07:08 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 03/28/2023 at 06:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in smoke detector not operating correctly, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Per Licensee will purchase and install a new one.
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
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Based on record review, the licensee did not comply with the section cited above due to not available in child's file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Licensee will have parent fill out to keep in child's file.
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:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/28/2023 07:08 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 03/28/2023 at 06:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

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 in that a 15 min sleep log was not available or being conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2023
Plan of Correction
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Per Licensee will being using log for each child under 24 months each day when child sleeps.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023


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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PENA FAMILY DAY CARE
FACILITY NUMBER: 198002693
VISIT DATE: 03/28/2023
NARRATIVE
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Per Licensee, there are no weapons, firearms on the premises. There are safe toys, play equipment and materials observed for children. Children’s records were available for review and were found to be complete except for a few that required a signature. Licensee understands that fire extinguishers need to be serviced yearly or a new fire extinguisher can be purchased. The last service was done in August 2022. The carbon monoxide detector located in the den area was tested and operable. The smoke detector was not functioning and per Licensee will be replacing. The Licensee and assistant have current Pediatric First Aid and CPR, which will expire August 2024.

Proof of immunization against influenza, pertussis, and measles for the Licensee and her assistant was readily available during today’s inspection. The Licensee and assistant have taken the Mandated Reporter Training and will need to be renewed August 10, 2024.

During visit LPA observed that play yard had pillow, blankets, and toys where infant (12 months and younger) children sleep. Per Licensee the infant is 10 months old. LPA consulted with Safe Sleep regulations. LPA consulted with Licensee regarding the 15-minute sleep log to be conducted with all children birth to 24 months. Per Licensee she currently has 2 infant children.

Two (2) Technical Violations were issued as Licensee was not able to will provide documentation provided for Fire or Earthquake Drill log and parent board was missing the following documents: California Child Passenger Safety Law (PUB269), Notification of Parents' Rights (PUB394), Earthquake Preparedness Checklist (LIC9148). LPA printed and provided documents to the Licensee, so that it be posted for parents.


LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. 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.
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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PENA FAMILY DAY CARE
FACILITY NUMBER: 198002693
VISIT DATE: 03/28/2023
NARRATIVE
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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. 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

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 will be assessed if this regulation is violated.

Based on LPAs observations and records review, the following deficiency listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

LPA informed the licensee to provide a copy of this licensing report dated 3/28/2023 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.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit made by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.



Exit interview was conducted, appeal rights were given, and a copy of this report was reviewed with the Licensee, Idalia Pena.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC809 (FAS) - (06/04)
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