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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015668
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:48:44 PM


Document Has Been Signed on 02/24/2023 03:48 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:BURGUENO FAMILY CHILD CAREFACILITY NUMBER:
198015668
ADMINISTRATOR:BURGUENO, ELIZABETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 255-3433
CITY:LOS ANGELESSTATE: CAZIP CODE:
90065
CAPACITY:14CENSUS: 5DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Licensee Elizabeth BurguenoTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Veronica Martinez Garza conducted an unannounced annual 1-year required inspection at the above facility on 02/24/23 at 01:14PM. A COVID risk assessment was conducted upon entry- appropriate PPE was used. LPA met with Elizabeth Burgueno, Licensee who guided analyst on a tour of the facility. There were 05 napping children present during this inspection. Per licensee, 08 children are enrolled. Present during the inspection was the Licensee’s husband. Operation hours are Monday – Friday 07:00AM – 05:30PM.

This is a one-story home which consists of 3 bedrooms, 2 bathrooms, living room, dining room, kitchen, side yards (fenced) and front yard (fenced). Per Licensee, family members residing in the home are 2 adults and 0 minors. All individuals present in the home have obtained a criminal record clearance or exemption prior to working, residing, or volunteering in a licensed home.Individuals living in the home are identified on the attached LIC811.

Areas accessible to children include living room, dining room, bedroom #1, 1 bathroom (next to bedroom #1), and front yard (fenced) for play. The bathroom children use was observed to be safe and sanitary.

Per licensee, areas off limits to children and parents include 2 bedrooms, 1 bathroom, and side yards (fenced).

**Rooms that are off-limits need to be made inaccessible during operating hours**

LPA toured all areas identified on the facility sketch used by children during this visit and were inspected for safety comfort, and cleanliness. LPA observed safe toys, play equipment and materials for children. Napping: LPA observed appropriate napping equipment play yards and mats located in the living room and in bedroom #1. LPA observed that play yards are free from loose articles and objects. There are no objects hanging above or attached to the side of the play yards.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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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: BURGUENO FAMILY CHILD CARE
FACILITY NUMBER: 198015668
VISIT DATE: 02/24/2023
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LPA observed that the play yards and mats do not hinder the entrance or exit to and from the space they are sleeping in. Mattresses were observed to be firm and covered with a fitted sheet that is appropriate to the mattress size. Per licensee, children nap in the living room and bedroom #1. The licensee does understand that licensing staff may have access to off-limit areas during inspection visit if necessary.

Per licensee, food is provided to all children in care. There is telephone service via a landline. There is central and wall unit for ventilation and heating.

Detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock.

At 03:17PM smoke and carbon monoxide detectors were tested and are operable. The valve on the required 3A 40BC fire extinguisher indicates fully charged and was serviced on 06/10/22, as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually.

LPA observed a first aid kit readily available in the dining room, front yard (fenced) and bedroom #1. Isolation area for sick children waiting to be picked up is in the living room of the home with supervision.

Per Licensee, there are no firearms or weapons stored in the home.

LPA observed the following required posted documentation in the living room 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- Emergency Disaster Plan and Disaster drill log. All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Last drill documented was 02/13/23. Children's roster was reviewed and is current.

Currently children use the front yard (fenced) for outdoor play with adequate shade and age-appropriate play equipment for children in care. LPA did not observe any objects that could be hazardous to children in care. Licensee understands that children should be supervised at all times.

LPA did not observe any pools, spas, hot tubs, fishponds, or similar bodies of water during the inspection.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
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: BURGUENO FAMILY CHILD CARE
FACILITY NUMBER: 198015668
VISIT DATE: 02/24/2023
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Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

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). Children's records were observed to be complete.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, expires 10/02/23, LIC 508- Criminal Record Statement, Proof of immunizations 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 and Licensee's husband did not have proof of immunizations.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018, any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers Licensee and Licensee's husband are missing the Mandated Reporter Training Certificate.

The licensee is operating within proper capacity and ratios. LPA observed licensee to be present at the home and providing adequate care and supervision.

Currently licensee does care for infants. 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. LPA provided PIN 20-24-CCP and PUB 217 Never Shake a Baby Brochure. LPA provided consultation on LIC 9227 and 15-minute documentation. Per the licensee, infants sleep in the living room.

No infant walkers, No baby bouncers, No Johnny jumpers, No exersaucers and any other item that falls into that category.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
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: BURGUENO FAMILY CHILD CARE
FACILITY NUMBER: 198015668
VISIT DATE: 02/24/2023
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Incidental Medical Services (IMS) policy was discussed. Per Licensee, there are no children on medications. 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

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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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

LPA advised the licensee to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

The following deficiencies were cited in accordance with Title 22 of the California Code of Regulations and Health & Safety Codes. Please see 809D for documentation of deficiencies.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
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: BURGUENO FAMILY CHILD CARE
FACILITY NUMBER: 198015668
VISIT DATE: 02/24/2023
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 was reviewed with Licensee Elizabeth Burgueno and provided Appeal Rights.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2023 03:48 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: BURGUENO FAMILY CHILD CARE
FACILITY NUMBER: 198015668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

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 on observation, interview and ecord review, the licensee did not comply with the section cited above in licensee and licensee;s husband did not have proof of Mandated Reporter Training Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Per licensee, she will submit proof of Mandated Reporter Training Certificate to LPA by due 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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Based on observation, interview and record review, the licensee did not comply with the section cited above in licensee and licensee's husband do not have immunization record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Per licensee, she will submit proof of immunizations to LPA by due 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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 02/24/2023 03:48 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: BURGUENO FAMILY CHILD CARE
FACILITY NUMBER: 198015668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

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 observation, interview and record review, the licensee did not comply with the section cited above in licensee and licensee's husband do not have proof of influenza vaccination which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Per licensee, she will submit proof of influenza vaccination to LPA by due date.
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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