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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011859
Report Date: 06/07/2022
Date Signed: 06/07/2022 04:40:50 PM


Document Has Been Signed on 06/07/2022 04:40 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:ORTIZ FAMILY CHILD CAREFACILITY NUMBER:
198011859
ADMINISTRATOR:ORTIZ, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 813-9540
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY:14CENSUS: DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Guadalupe Ortiz, LicenseeTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fabiola Vasquez conducted an unannounced annual required inspection at the above facility on 06/07/22 at 02:00 9 PM. LPA met with Guadalupe Ortiz, Licensee who guided analyst on a tour of the facility at approximately 2:10 PM. There were 06 children with licensee, present when LPA arrived. Facility capacity is in compliance for a Large Family Child Care Home. There are 0 children and 5 adults that reside in the home. Visit was conducted in Spanish.

There is a pool on the premises. Pool is surrounded by a 5 foot fence to the South and East. To the North and West and the neighbor's wall. Fence has self-latching and closing gate that swings away from the pool. Fence meets Licensing requirements.

This is a one-story home which consists of four bedrooms one of the bedrooms was extended to add a den that is used as a playroom, two bathrooms, kitchen, dining room, living room, front and back yard (fenced). Hours of operation are Mon-Fri 6:00 AM - 6:00 PM. Food is provided by Licensee.

Areas off limits include: Three bedrooms, one bathroom, front yard area, converted garage, and pool area.
Areas accessible to children include Den (Converted into a play room), bathroom adjacent to the den, right section of the back yard opposite from the pool.

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 05/30/22.

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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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


Document Has Been Signed on 06/07/2022 04:40 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: ORTIZ FAMILY CHILD CARE
FACILITY NUMBER: 198011859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

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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3
4
Based on LPAs record review Child #1 is missing proof of safe sleeplog the licensee did not comply with the section cited above which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2022
Plan of Correction
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Per licensee she will submit proof to LPA by POC.
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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3
4
Based on record review Staff #3, Staff #4 was missing proof of TB clearance, 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: 06/14/2022
Plan of Correction
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Per licensee she will submit proof to LPA by POC.

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: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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: ORTIZ FAMILY CHILD CARE
FACILITY NUMBER: 198011859
VISIT DATE: 06/07/2022
NARRATIVE
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Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged date services 04/26/22. The home maintains telephone service via landline. 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.

Per licensee 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 the den away from the other children. Per Licensee there are no firearms or weapons stored in the home.

Infant Care: Currently licensee cares for 1 infant birth to 24 months. LPA did not observe any infants during the visit. Per licensee, the infant sleeps on a mat. LPA informed licensee that the infant is required to sleep in a crib or play yard. Per licensee she had a play yard for the infant and brings it out when they go outside. LPA informed licensee that she has to have the play yard out during the hours that the infant is in care. LPA observed the play yard in the storage room.

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: She sits with infant when child is asleep. Child #1 is missing safe sleep log.

Children are using the right section of the back yard opposite from the pool 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)

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

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 3 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: ORTIZ FAMILY CHILD CARE
FACILITY NUMBER: 198011859
VISIT DATE: 06/07/2022
NARRATIVE
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Staff records were reviewed for approved Pediatric First Aid and CPR certification, dated: 12/01/22, 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.

S3, S4 are missing proof of TB clearance.

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.
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

See deficiencies cited on today’s visit on 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.

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

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 5 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: ORTIZ FAMILY CHILD CARE
FACILITY NUMBER: 198011859
VISIT DATE: 06/07/2022
NARRATIVE
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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 Guadalupe Ortiz, Licensee.

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

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5