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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011890
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:58:51 PM


Document Has Been Signed on 06/24/2022 01:58 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:VAZQUEZ FAMILY CHILD CAREFACILITY NUMBER:
198011890
ADMINISTRATOR:VAZQUEZ, MARTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 812-9614
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:14CENSUS: 0DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Martha Vasquez, LicenseeTIME COMPLETED:
02:15 PM
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                Visit conducted in Spanish
Licensing Program Analyst (LPA) Fabiola Vasquez conducted an unannounced one year required inspection at the above facility on 06/24/22 at 8:30 AM. LPA met with Martha Vasquez, Licensee who guided analyst on a tour of the facility at approximately 8:40 AM. There were 0 children and licensee, present when LPA arrived. Facility capacity is in compliance for a Large Family Child Care Home. There are 0 children and 3 adults that reside in the home.

Per licensee, on 5/2020 City of Azusa legalized the attached garage as a home. The updated address on the lot is; Main house: 146 N Vernon, Ave, Azusa CA 91702. Back house :144 N. Vernon Ave, Azusa CA 91702.
There are two homes on the lot. The main home which is the licensed facility is in the front of the lot which consist of 3 bedrooms, 3 bathrooms, kitchen, dining room, living room (FIREPLACE: inaccessible), Family room (convert into a playroom), side yard (converted into a play yard). The second home (attached garage) consist of I bedroom, 1 bath, living room, and kitchen. LPA toured the home; per licensee the home is empty and it is used as a storage area. Hours of operation are Monday-Sunday 6:00 AM to 5:00 AM. Food is provided by Licensee. LPA observed 3 dogs in the back yard inaccessible to children.

Licensee was provided an LIC 999 to update the facility sketch.

Per licensee areas off limits to children and parents include: 3 bedrooms, 2 bathrooms, kitchen, dining room, living room (FIREPLACE: inaccessible), attached garage (converted into a small home with its own address 644 Vernon), backyard (fenced) and pool located in the back yard.

Per licensee areas accessible to children are: Family room (Currently being used as a playroom), 1 bathroom located in the den and the side yard (converted into a play yard).

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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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 06/24/2022 01:58 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: VAZQUEZ FAMILY CHILD CARE
FACILITY NUMBER: 198011890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022

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 onLPAs recoed review Licensee and staff 2 were missing proof on Child abuse certificate training. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2022
Plan of Correction
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Per licensee she and her son will complete the training and submit proof to LPA by POC date.
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 trecord review licensee is missing proof of MMR which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2022
Plan of Correction
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Per licensee she will make a doctors appointment and recieve the MMR and 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: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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: VAZQUEZ FAMILY CHILD CARE
FACILITY NUMBER: 198011890
VISIT DATE: 06/24/2022
NARRATIVE
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The LPA toured all areas used by children during this visit. 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 06/2022.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher was purchased during the visit dated: 6/24/22. 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 did not observed a wall heater, the home has central air. 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 on the side in 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

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. LPA observed a pool in the back yard has a fence around it. Gate was tested and is operating today.



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: 9/3/23. 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 dated: Licensee is missing proof of: MMR. Licensee, Staff #1, Staff #2 are missing proof of: Mandated Reporter Training Certificate.

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

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
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: VAZQUEZ FAMILY CHILD CARE
FACILITY NUMBER: 198011890
VISIT DATE: 06/24/2022
NARRATIVE
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LPA did not observe children in care during the visit.
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 cited on today’s visit. See LIC 809

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.

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

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 4 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: VAZQUEZ FAMILY CHILD CARE
FACILITY NUMBER: 198011890
VISIT DATE: 06/24/2022
NARRATIVE
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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 and appeal rights were reviewed with the licensee, Martha Vasquez.

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

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5