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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198003334
Report Date:
07/06/2022
Date Signed:
07/06/2022 02:28:00 PM
Document Has Been Signed on
07/06/2022 02:28 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 CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
CACERES FAMILY CHILD CARE
FACILITY NUMBER:
198003334
ADMINISTRATOR:
CACERES, ESTHER
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(562) 413-8658
CITY:
DOWNEY
STATE:
CA
ZIP CODE:
90240
CAPACITY:
14
CENSUS:
7
DATE:
07/06/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:10 AM
MET WITH:
Licensee, Esther Caceres
TIME COMPLETED:
02:45 PM
NARRATIVE
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On 07/06/2022 at 9:10 am Licensing Program Analysts (LPAs) Monique Ayala and Austin Estrada conducted an unannounced inspection at the facility noted above and met with Licensee, Esther Caceres. The purpose of the inspection was to conduct the Required - 1 Year inspection. The operating hours of the facility is Monday through Friday from 6:30 AM to 5:30 PM. Entrance Checklist (LIC 126) was provided to the Licensee upon arrival. Individuals residing in the home were discussed and noted. At the time of the inspection, 7 children were present. Per Licensee, she does not have a dual license at this address.
All areas identified on the facility sketch were inspected. This facility is a single family home that consists of three (3) bedrooms, two (2) bathrooms, dining room, family room, play room, office, kitchen, laundry room, attached garage, and fenced backyard.
Areas that are accessible to children include: the play room, family room, 1 bathroom, and backyard (fenced). Per Licensee, the children utilize the backyard (fenced) for outdoor activity.
Areas off-limits to children include: 3 bedrooms, 1 bathroom, dining room, kitchen, laundry room, office, and attached garage, and both outside areas on the side of the home. LPAs observed the following off-limit areas accessible to children in care: dining room, kitchen, 3 bedrooms, office, and one side of the home from the backyard. The Licensee was advised that off-limit areas must be made inaccessible during operating hours.
The following documents were posted in a prominent, publicly accessible area: Facility License and Notification of Parents' Rights (PUB 394). The Earthquake Preparedness (LIC 9148) was not posted and the Licensee did not have an Emergency Disaster Plan (LIC 610A) readily available for review. Licensee did not have verification of Disaster and Fire Drills.
SUPERVISOR'S NAME:
Valarie Cook
TELEPHONE:
(323) 513-3858
LICENSING EVALUATOR NAME:
Monique Ayala
TELEPHONE:
(323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE:
07/06/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
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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 CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
CACERES FAMILY CHILD CARE
FACILITY NUMBER:
198003334
VISIT DATE:
07/06/2022
NARRATIVE
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Areas used by children were inspected for safety, comfort, heating, cleanliness and telephone service. The facility has central air and heating. The home does not have a fireplace or any wall heaters. Detergents, cleaning compounds and medicines were made inaccessible to children in care. At 10:06 am, LPAs observed hazardous items located on the side of the home, which were made accessible to children in care from the backyard. At 10:07 am, LPAs also observed a trampoline located in the backyard, which Licensee stated is used by the children in care. LPA Ayala informed the Licensee that trampolines are not permitted at the family child care home. Per Licensee, there are no poisons kept in the home. Licensee was advised that if any poisons are purchased, it is required to be locked with a key or combination lock.
Per Licensee, there are no firearms, weapons or bodies of water on the premises. Per Licensee, the only pet kept in the home is a guinea pig. LPAs observed age appropriate toys and napping equipment for children. LPAs did not observe electrical outlet covers throughout the home. At the time of the inspection, Licensee placed electrical outlet covers in the play room, family room, and the office that is located next to the play room. Licensee disclosed that the office is considered off-limits however, LPAs observed the office door open that did not have a door knob.
LPAs observed the required fire extinguisher (2A-10BC) that is fully charged and was last serviced on 07/02/2021. Licensee was reminded to have the fire extinguisher serviced yearly. Smoke detectors were tested and are operable. The Licensee did not have an operable carbon monoxide detector. First Aid kits and emergency supplies are available and located in the play room.
Licensee stated that she provides breakfast, lunch, and a snack to children. Per Licensee, children do not bring food from home. Licensee was informed that if food is brought from the child's home it shall be labeled with the child’s name and properly stored or refrigerated.
Licensee did not have proof of completion for Pediatric First Aid and CPR (EMSA-approved), Preventative Health and Safety Training (EMSA-approved), and Mandated Reporter Training (AB 1207). Licensee did not have proof of immunization against measles, pertussis, and influenza. Licensee did not have the Criminal Record Statement (LIC 508), Statement Acknowledging Requirement to report Child Abuse (LIC 9108), Employee Rights (LIC 9052), and TB clearance or risk assessment readily available for review. Licensee was advised that the Mandated Reporter training (AB 1207) must be completed every 2 years and is available at
www.mandatedreporterca.com
.
SUPERVISOR'S NAME:
Valarie Cook
TELEPHONE:
(323) 513-3858
LICENSING EVALUATOR NAME:
Monique Ayala
TELEPHONE:
(323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE:
07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/06/2022
LIC809
(FAS) - (06/04)
Page:
2
of
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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 CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
CACERES FAMILY CHILD CARE
FACILITY NUMBER:
198003334
VISIT DATE:
07/06/2022
NARRATIVE
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LPAs conducted record reviews of 7 children's files. Based on the record reviews, 6 of the 7 children's records were missing the required immunization record. LPAs found that 2 of the 7 children's records were missing the required Notification of Parents' Rights (LIC 995A). LPAs also found that 1 of 7 children's records was missing the Consent for Emergency Medical Treatment (LIC 627) and Affidavit Regarding Liability Insurance (LIC 282).
LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage 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.
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 in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PINs), Program Quarterly Update Newsletters and other important information communication platforms.
SUPERVISOR'S NAME:
Valarie Cook
TELEPHONE:
(323) 513-3858
LICENSING EVALUATOR NAME:
Monique Ayala
TELEPHONE:
(323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE:
07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/06/2022
LIC809
(FAS) - (06/04)
Page:
3
of
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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 CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
CACERES FAMILY CHILD CARE
FACILITY NUMBER:
198003334
VISIT DATE:
07/06/2022
NARRATIVE
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LPA provided assistance to the Licensee on how to access forms, regulations and quarterly updates on the Child Care Licensing website at:
www.ccld.ca.gov
.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at
https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe
and select the Child Care option to receive email communication.
To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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-care-licensing/inspection-process
.
LPA Ayala requested that the following documents be submitted to the Monterey Park Child Care Regional Office located at 1000 Corporate Center Dr., Suite 200B, Monterey Park, CA 91754 by July 22nd: an updated Application for a Family Child Care Home License (LIC 279), updated Current Children in Your Home (LIC 279B), updated Facility Sketch (LIC 999A), and Proof of Control of Property (mortgage bill, tax bill, deed).
Deficiencies were cited per Title 22 regulations (refer to deficiency pages). LPA also issued Advisory Notes - Technical Violations during today's inspection (refer to LIC 9102TV pages). A follow-up inspection was scheduled for Friday, July 22nd at 9:00 am to ensure that corrections have been made.
A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with Licensee, Esther Caceres.
SUPERVISOR'S NAME:
Valarie Cook
TELEPHONE:
(323) 513-3858
LICENSING EVALUATOR NAME:
Monique Ayala
TELEPHONE:
(323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE:
07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/06/2022
LIC809
(FAS) - (06/04)
Page:
14
of
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Document Has Been Signed on
07/06/2022 02:28 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 CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
CACERES FAMILY CHILD CARE
FACILITY NUMBER:
198003334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/06/2022
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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as the facility does not have an operable carbon monoxide detector which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2022
Plan of Correction
1
2
3
4
Licensee will ensure that an operable carbon monoxide detector is installed inside the facility.
Type B
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as LPAs observed a trampoline in the backyard that the Licensee stated the children in care use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2022
Plan of Correction
1
2
3
4
Licensee will remove the trampoline from the facility.
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:
Valarie Cook
TELEPHONE:
(323) 513-3858
LICENSING EVALUATOR NAME:
Monique Ayala
TELEPHONE:
(323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE:
07/06/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/06/2022
LIC809
(FAS) - (06/04)
Page:
4
of
14
Document Has Been Signed on
07/06/2022 02:28 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 CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
CACERES FAMILY CHILD CARE
FACILITY NUMBER:
198003334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/06/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan.
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 as the Licensee did not have an Emergency Disaster Plan (LIC 610A) readily available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2022
Plan of Correction
1
2
3
4
The Licensee will have a completed Emergency Disaster Plan (LIC 610A) available at the facility.
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 as the Licensee did have proof of completion for the required Mandated Reporter Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2022
Plan of Correction
1
2
3
4
The Licensee will complete the required Mandated Reporter Training and have the certificate of completion available at the facility.
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:
Valarie Cook
TELEPHONE:
(323) 513-3858
LICENSING EVALUATOR NAME:
Monique Ayala
TELEPHONE:
(323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE:
07/06/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/06/2022
LIC809
(FAS) - (06/04)
Page:
5
of
14
Document Has Been Signed on
07/06/2022 02:28 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 CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
CACERES FAMILY CHILD CARE
FACILITY NUMBER:
198003334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/06/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.
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 as the Licensee did not have available proof of immunization against pertussis, measles, influenza, and a TB clearance or risk assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2022
Plan of Correction
1
2
3
4
The Licensee will ensure that her immunization record (pertussis, measles, influenza, and TB clearance or risk assessment) is readily available at the facility.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) 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 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 as the Licensee did not have proof of completion for the Preventative Health and Safety Training and Pediatric First Aid and CPR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2022
Plan of Correction
1
2
3
4
Licensee will complete the required trainings and have proof of completion readily available for review.
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:
Valarie Cook
TELEPHONE:
(323) 513-3858
LICENSING EVALUATOR NAME:
Monique Ayala
TELEPHONE:
(323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE:
07/06/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/06/2022
LIC809
(FAS) - (06/04)
Page:
6
of
14
Document Has Been Signed on
07/06/2022 02:28 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 CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
CACERES FAMILY CHILD CARE
FACILITY NUMBER:
198003334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/06/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 6 out of 7 children [C1, C2, C3, C4, C6 and C7] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2022
Plan of Correction
1
2
3
4
The Licensee will ensure that the required immunization records are obtained and kept in the children's file for review.
Type B
Section Cited
CCR
102417(g)(7)
(g)(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 7 children's records [C5] did not have the Consent for Emergency Medical Treatment (LIC 627) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2022
Plan of Correction
1
2
3
4
The Licensee will ensure that the required document is completed and kept in the child's record for review.
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:
Valarie Cook
TELEPHONE:
(323) 513-3858
LICENSING EVALUATOR NAME:
Monique Ayala
TELEPHONE:
(323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE:
07/06/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/06/2022
LIC809
(FAS) - (06/04)
Page:
7
of
14
Document Has Been Signed on
07/06/2022 02:28 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 CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
CACERES FAMILY CHILD CARE
FACILITY NUMBER:
198003334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/06/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 7 children [C5 and C6] did not have on record the required Notification of Parents' Rights (LIC 995A) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2022
Plan of Correction
1
2
3
4
The Licensee will ensure that the required document is completed and kept in the children's file for review.
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:
Valarie Cook
TELEPHONE:
(323) 513-3858
LICENSING EVALUATOR NAME:
Monique Ayala
TELEPHONE:
(323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE:
07/06/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/06/2022
LIC809
(FAS) - (06/04)
Page:
8
of
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Document Has Been Signed on
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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 CENTER DR 200B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
CACERES FAMILY CHILD CARE
FACILITY NUMBER:
198003334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/06/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 7 children's records (C5) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2022
Plan of Correction
1
2
3
4
The Licensee will ensure that the required document is completed and kept in the child's record for review.
Type B
Section Cited
CCR
102417(g)
102417(g) The home shall be free from defects or conditions which might endanger a child.
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 as all off-limit areas were made accessible to children in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/22/2022
Plan of Correction
1
2
3
4
The Licensee will ensure that all off-limit areas are made inaccessible to children while children are in care.
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:
Valarie Cook
TELEPHONE:
(323) 513-3858
LICENSING EVALUATOR NAME:
Monique Ayala
TELEPHONE:
(323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE:
07/06/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/06/2022
LIC809
(FAS) - (06/04)
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