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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198005157
Report Date: 06/14/2022
Date Signed: 06/14/2022 11:38:48 AM

Document Has Been Signed on 06/14/2022 11:38 AM - 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:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
198005157
ADMINISTRATOR:PEREZ, ALBAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 476-0138
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Alba PerezTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst’s (LPAs) Fabiola Vasquez and Veronica Martinez conducted an unannounced annual required inspection at the above facility on 06/14/22 at 8:30 AM. LPAs met with Alba Perez, Licensee who guided analysts on a tour of the facility at approximately 8:35 AM. There were 4 children and with licensee present when LPAs arrived. Facility capacity is in compliance for a Large Family Child Care Home. There are 0 children and 2 adults that reside in the home. At 8:40 AM LPAs observed a knife on the kitchen counter accessible to children in care, knife was removed during the inspection.

This is a one story home which consists of three bedrooms, two-bathroom, kitchen, dining room, living room, den, attached garage, front and back yard (fenced). Per Licensee, areas off limits to children and parents include backyard and attached garage. Hours of operation are Mon-Fri 6:00 AM - 5:00PM. Food is provided by Licensee.

Areas accessible to children were inspected as follows: Den (Converted into a play area), and back yard. Per licensee, children will be using the bedroom adjacent to the den. LPA provided an LIC 999 to update accessible areas to children.

Areas off limits include: Living room, kitchen, three bedrooms, one bathroom, front yard and attached garage.

LPA observed the following required posted documentation in the main entry way of the den: 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 04/21/22.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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 6
Document Has Been Signed on 06/14/2022 11:38 AM - It Cannot Be Edited


Created By: Fabiola Vasquez On 06/14/2022 at 10:39 AM
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 198005157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, at 8:40 AM LPAs observed a knife on the kitchen counter accessible to children in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2022
Plan of Correction
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The knife was removed and put awat during the inspection
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:Claudia Guangorena
LICENSING EVALUATOR NAME:Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/14/2022 11:38 AM - It Cannot Be Edited


Created By: Fabiola Vasquez On 06/14/2022 at 10:39 AM
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 198005157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations at 8:52 AM LPAs observed the play structure to have exposed sharp plastic on a step leading up to the slide. A wooden table with exposed splinters, an umbrella stand with a extended pole facing up, accessible to the children. LPAs observed the fire extinguisher to be fully charged, License is missing proof of purchase, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2022
Plan of Correction
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Removed during the visit; wooden table with exposed splinters, an umbrella stand with a extended pole facing up, accessible to the children. Licensee will submit proof 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, Staff # 2 is missing proof; LIC 508- Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza, TB clearance or risk assessment, LIC 9108- Statement Acknowledging which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2022
Plan of Correction
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Per licensee she is having the assistant complete the forms and immunizations on Wednesday when she returns.
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 Guangorena
LICENSING EVALUATOR NAME:Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 198005157
VISIT DATE: 06/14/2022
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Smoke and carbon monoxide detectors were tested and are operable. LPAs observed the fire extinguisher to be fully charged, License is missing proof of purchase. 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. LPAs did not observe a wall heater. LPA observed that detergents, cleaning compounds and medication are stored in in an area that is inaccessible to children. Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, Licensee removed a glade spray located in the children’s restroom during the visit. Isolation area for sick children waiting to be picked is the room adjacent to the den, away from the other children. Per Licensee there are no firearms or weapons stored in the home.
Infant Care: Currently licensee is not caring for infants’ birth to 24 months.

Children are using the back 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. At 8:52 AM LPAs observed the play structure to have exposed sharp plastic on a step leading up to the slide. A wooden table with exposed splinters, an umbrella stand with a extended pole facing up, accessible to the children.

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.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, dated: 05/22/ 23, LIC-501: Personnel Record, LIC 508- Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunization's against measles, pertussis and influenza, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate dated: 10/11/23. Staff # 2 is missing proof; LIC 508- Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza, TB clearance or risk assessment, LIC 9108- Statement Acknowledging.



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.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 198005157
VISIT DATE: 06/14/2022
NARRATIVE
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LPA observed that licensee is implementing COVID-19 precautions and procedures.

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

Deficiencies are being cited on today’s visit. See LIC 809D.

LPAs informed licensee Alba Perez, that this report dated 06/14/22 documents # 1 Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPAs informed the licensee to provide a copy of this licensing report dated 06/14/22 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.

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.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 198005157
VISIT DATE: 06/14/2022
NARRATIVE
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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, Alba Perez.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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