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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198008599
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:03:16 PM


Document Has Been Signed on 03/28/2022 04:03 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:ZAMBRANO FAMILY CHILD CAREFACILITY NUMBER:
198008599
ADMINISTRATOR:SALOME ZAMBRANOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 969-3048
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:14CENSUS: 4DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Salome Zambrano, LicenseeTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Fabiola Vasquez and Steven Tung conducted an unannounced required inspection at the above facility on 03/28/22 at 12:30 PM. Visit was conducted in Spanish. LPA met with Salome Zambrano, Licensee who guided analyst on a tour of the facility at approximately 12:35 PM. There were 4 children (3 being infants) present adults were Licensee, S1,S2,S3 present upon arrival. Facility capacity is in compliance for a Large Family Child Care Home. Per licensee 4 adults and 3 minors live reside in the home.

This is a one-story home which consists of three bedrooms, one restroom, kitchen, dining room, Living room, shed, detached garage, front and back yards (fenced). Per Licensee, areas off limits to children and parents include: the bedrooms, detached garage, and shed. Hours of operation are Mon-Fri 6:00 AM - 6:00PM. Food is provided by Licensee. LPAs observed bird cages in the backyard inaccessible to children.

LPA observed the following required posted documentation in the main entry way of the facility: 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 2/20/22.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged. The home maintains telephone service via landline and cell phone. The home is observed to be clean and orderly. There are toys and other age appropriate material available for children. LPA observed a wall heater in the living room (screened). LPA observed that detergents, cleaning compounds and medication are stored in in an area that is inaccessible to children. LPAs observed a can of Lysol, 2 Clorox containers and a Clorox spray accessible to children. Licensee understands that all poisons must be lock. Isolation area for sick children waiting to be picked up is away from the other children. Per Licensee there are no firearms or weapons stored in the home.

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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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 9


Document Has Been Signed on 03/28/2022 04:03 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: ZAMBRANO FAMILY CHILD CARE
FACILITY NUMBER: 198008599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPAs observed in the dinning area stalked up papers, containers used for storage. Plastic containers on top of a shelf in the play area, plastic bags with items inside which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
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Per Licensee will submit proof to LPA by POC date:
Type B
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 observation, LPAs observed in the a television screen on top of the entertainment center. Wires drapping from outlets. Plastic bags accessible to children.
POC Due Date: 04/04/2022
Plan of Correction
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Per Licensee will submit proof to LPA by POC date:

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: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9


Document Has Been Signed on 03/28/2022 04:03 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: ZAMBRANO FAMILY CHILD CARE
FACILITY NUMBER: 198008599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)(A)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPAs observed a Lysol spray , 2 clorox wipes conatiners and clorox spray in the restroom accessible to children which poses a potential health, safety or personal rights risk to persons in care.


POC Due Date: 04/04/2022
Plan of Correction
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Per Licensee will submit proof to LPA by POC date:
Type B
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 LPAs observation. LPAs observed loose blankets inside the crib which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
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Per Licensee will submit proof to LPA by POC date:

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: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 03/28/2022 04:03 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: ZAMBRANO FAMILY CHILD CARE
FACILITY NUMBER: 198008599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Child (C) C1, C2, C3 were missing proof of Safe Sleep Plan documentation. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
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Per Licensee will submit proof to LPA by POC date:
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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POC Due Date: 04/04/2022
Plan of Correction
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Per Licensee will submit proof to LPA by POC date:

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: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 03/28/2022 04:03 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: ZAMBRANO FAMILY CHILD CARE
FACILITY NUMBER: 198008599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review Licensee, S1, S2 missing proof: LIC 9052 which posesa potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
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Per Licensee will submit proof to LPA by POC date:
Type B
Section Cited
CCR
102416.1(a)(11)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (11) A signed statement regarding their criminal record history as required by Section 102370(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review Licensee, S1, S2 missing proof: LIC 9052 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
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Per Licensee will submit proof to LPA by POC date:

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: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 03/28/2022 04:03 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: ZAMBRANO FAMILY CHILD CARE
FACILITY NUMBER: 198008599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee, S1, and S2 missing proof of MMR, TDAP, Influenza and TB clearance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
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Per Licensee will submit proof to LPA by POC date:
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's 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).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, C3, C4 are missing proof the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
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Per Licensee will submit proof to LPA by POC date:

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: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 6 of 9


Document Has Been Signed on 03/28/2022 04:03 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: ZAMBRANO FAMILY CHILD CARE
FACILITY NUMBER: 198008599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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3
4
Based on record review Child (C) C3 were missing proof, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
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3
4
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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2
3
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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 7 of 9


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: ZAMBRANO FAMILY CHILD CARE
FACILITY NUMBER: 198008599
VISIT DATE: 03/28/2022
NARRATIVE
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Infant Care: Currently licensee cares for infants birth to 24 months. LPA observed two cribs in the dinning room. Napping equipment does not block entrances or exits. Infant mattresses were observed to be firm with tightly fitted sheets. LPAs observe blankets inside the cribs. LPAs did not observe bumpers, objects hanging, or objects attached to the cribs. Per licensee wet or soiled sheets are put in a basket and washed by licensee. Each infant has their own crib and bedding. Bedding changed daily. LPA discussed with licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months. Licensee states the following as a sleep supervision plan for infants: We sit in the main care area and supervise the children.

Child (C) C1, C2, C3 were missing proof of Safe Sleep Plan documentation. Child (C) C3 is missing the LIC 9227 Individual Sleeping Plan.



Children are using the front 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, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months).



Child (C) C3, C4 are missing proof of Notification of Parent's Rights.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, 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, S1, S2, S3 Missing: Flu/TB/Tdap/MMR.

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.

LPA observed that licensee is implementing COVID-19 precautions and procedures.

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

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: ZAMBRANO FAMILY CHILD CARE
FACILITY NUMBER: 198008599
VISIT DATE: 03/28/2022
NARRATIVE
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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

The following deficiencies are cited in accordance with Title 22 of California Code of Regulations. See 809 D attached.

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, Salome Zambrano.

PAGE 3 OF 3

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

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 9 of 9