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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198009860
Report Date: 03/28/2022
Date Signed: 03/28/2022 12:02:49 PM


Document Has Been Signed on 03/28/2022 12:02 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:DIAZ FAMILY CHILD CAREFACILITY NUMBER:
198009860
ADMINISTRATOR:LAURA DIAZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 815-5925
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:14CENSUS: 6DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Laura Diaz, LicenseeTIME COMPLETED:
12:15 PM
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Licensing Program Analysts(LPA's) Fabiola Vasquez and Steven Tung conducted an unannounced required inspection at the above facility on 03/28/22 at 8:40 AM. Visit was conducted in Spanish. LPAs met with Laura Diaz, Licensee who guided analyst on a tour of the facility at approximately 8:50 AM. There were six children with licensee 2 being infants. Approximately 9:20 Staff 2 arrived. Facility capacity is in compliance for a Large Family Child Care Home. Per licensee 2 adults and 1 child live in the home.

This is a single story home which consists of 2 bedrooms, 1 full bathroom and one half bathroom (used by licensee), living room (converted into a playroom), Dining-room, kitchen, attached garage, front and back yard. The following areas are used for day-care: Living Room and Dining Room/Kitchen area, 1 bedroom, 1 restroom, and the back yard (fenced). Off limit areas include:1 bedroom and 1 bathroom. Hours of operation are Mon-Fri 6:00 AM - 6:00PM. Food is provided by Licensee.

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 02/07/22.

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. 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 one of the main care bedrooms, 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)
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Document Has Been Signed on 03/28/2022 12:02 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: DIAZ FAMILY CHILD CARE
FACILITY NUMBER: 198009860

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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2
3
4
Based on record review, the licensee did not comply with the section cited above, C1,C4,C7 are missing proof.
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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2
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Per licensee will submit proof to LPA by POC date.
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, C4 is missing proof.
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: 2 of 4


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: DIAZ FAMILY CHILD CARE
FACILITY NUMBER: 198009860
VISIT DATE: 03/28/2022
NARRATIVE
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Infant Care: Currently licensee cares for infants birth to 24 months. LPA observed a play yard in the accessible bed room, LPAs observed 2 cribs in the living room area. Napping equipment does not block entrances or exits. Infant mattresses were observed to be firm with tightly fitted sheets. LPA did not observe loose objects, 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: Per licensee the bedroom accessible to children is sometimes used for napping in the morning. During the time that infants are napping she maintains the door open.

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. 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,



C4 was missing proof LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months). Child (C): C1, C4, C7 are missing proof of safe sleep documentation.

Staff records were reviewed for approved Pediatric First Aid and CPR certification (Ex: 10/2023), 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.

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: 3 of 4
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: DIAZ FAMILY CHILD CARE
FACILITY NUMBER: 198009860
VISIT DATE: 03/28/2022
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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

Deficiencies were cited in accordance with California Code of Regulations Title 22. See 809-D.

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 Laura Diaz.

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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: 4 of 4