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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198003902
Report Date: 08/17/2022
Date Signed: 08/17/2022 04:05:34 PM


Document Has Been Signed on 08/17/2022 04:05 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:FLORES-BARAJAS FAMILY CHILD CAREFACILITY NUMBER:
198003902
ADMINISTRATOR:FLORES-BARAJAS, ROSAURAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 927-0541
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY:14CENSUS: 0DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Rosaura FloresTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fabiola Vasquez conducted an unannounced Required - 1 Year annual inspection at the above facility on 08/17/22 at 11:55 PM. LPA met with S1 who guided analyst on a tour of the facility at approximately 12:00 PM. There were 0 children present when LPA arrived. Licensee, Rosaura Flores arrived shortly after at 12:15 PM who continued with the inspection. There are 0 children and licensee, 2 adult sons, 1 adult daughter who is away for school who reside in the home. Total adults residing in the home 4 adults. S2 arrived with 4 children at 1:45 PM. S2 picked up a child from school arrived back at 2:35 PM.

This is a one-story home which consists of three bedrooms, two-bathroom, kitchen, dining room, living room, den, drive way side yard (fenced), detached garage. The following areas are used for day-care: den with bathroom (daycare room), and side yard. Per Licensee, areas off limits to children and parents include: three bedrooms, one bathroom in the main house, kitchen, dining room, living room, driveway and detached garage. Hours of operation are Mon-Fri 6:00 AM -11:00 PM. Food is provided by Licensee.

LPA observed the following required posted documentation in the main entry way of the den where children enter into the daycare room., Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA reviewed facility records for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log. Last drill was conducted on 08/2022.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged date services 08/2022. The home maintains telephone service via cell phone. The home is observed to be clean and orderly. There are toys and other age appropriate material available for children. LPA did not observe a wall heater the home has central air. Detergents and cleaning compounds are stored in a storage area on the side of the home, medication are stored in the kitchen in a high shelf that is inaccessible to children. Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in the den near licensee, away from the other children. Per Licensee there are no firearms or weapons stored in the home. PAGE 1 OF 3
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 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: FLORES-BARAJAS FAMILY CHILD CARE
FACILITY NUMBER: 198003902
VISIT DATE: 08/17/2022
NARRATIVE
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Currently licensee cares do not care for infants.

Children are using the side yard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with.

LPA did not observe any objects that could be hazardous to children in care

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights. C1, C2, C3 missing proof of LIC 627. C3 is missing proof of LIC 700. C3 missing proof of LIC 282.



Staff records were reviewed for approved Pediatric First Aid and CPR certification, dated: 12/04/23. LIC-501: Personnel Record, LIC 508- Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunization's against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate.

Licensee and S2 are missing proof of Mandated Reporter Training Certificate.
S2 is missing proof of Pediatric First Aid and CPR certification, Proof of immunization's against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment,

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

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. 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm
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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 2 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: FLORES-BARAJAS FAMILY CHILD CARE
FACILITY NUMBER: 198003902
VISIT DATE: 08/17/2022
NARRATIVE
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Deficiencies cited on today’s visit, See LIC 809D.

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/process.

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.

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.

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, Rosaura Flores.

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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/17/2022 04:05 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: FLORES-BARAJAS FAMILY CHILD CARE
FACILITY NUMBER: 198003902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

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
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Based on record review licensee and staff 2 are missing proof of mandated reporter training. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Per licensee, she is going to submit a copy to LPA via email.
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
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Based on record review ,S2 is missing proof of Pediatric First Aid and CPR certification, Proof of immunization's against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Per licensee, she is going to submit a copy to LPA via email.

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: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/17/2022 04:05 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: FLORES-BARAJAS FAMILY CHILD CARE
FACILITY NUMBER: 198003902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review Staff 2 is missing proof, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2022
Plan of Correction
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Per licensee, she is going to submit a copy to LPA via email.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(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
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Based on record review C1, C2, C3 missing proof of LIC 627. C3 is missing proof of LIC 700. C3 missing proof of LIC 282. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2022
Plan of Correction
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Per licensee, she is going to submit a copy to LPA via email.

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: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5