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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015668
Report Date: 02/23/2024
Date Signed: 02/23/2024 03:12:19 PM


Document Has Been Signed on 02/23/2024 03:12 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
MONTEREY PARK CC RO, 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: 4DATE:
02/23/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Licensee Elizabeth BurguenoTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Veronica Martinez Garza conducted an unannounced Required 3-year inspection at the above facility on 02/23/24 at 12:50 p.m. LPA met with Licensee Elizabeth Burgueno who guided analyst on a tour of the facility. There were 04 children present during this inspection. Licensee’s husband was also present during this inspection. Per licensee, 07 children are enrolled.

Operation hours are Monday – Friday 07:30AM – 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). The children use the living room, dining room, bedroom #1, 1 bathroom (next to bedroom #1), and front yard (fenced) for play. Off limits to parents and children include: 2 bedrooms, 1 bathroom, and side yards (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.

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 yard. 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 with supervision. LPA observed a first aid kit readily available.

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.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3386
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: BURGUENO FAMILY CHILD CARE
FACILITY NUMBER: 198015668
VISIT DATE: 02/23/2024
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LPA reviewed facility records LIC 610- Emergency Disaster Plan and Disaster drill log, last drill documented was 08/20/23. All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Per Licensee, she will conduct the fire and disaster drill today after children wake up from their nap. Children’s roster was available during this inspection and was observed to be current.

LPA did not observe any pools, spas, hot tubs, fishponds, or similar bodies of water during the inspection. Per Licensee, there are no pets on the premises.

Licensee does understand that licensing staff may have access to off-limit areas during inspection visit if necessary.

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

Per licensee, food is provided to all children in care. There is a telephone service via a landline and cellphone. There is 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. Per licensee, there are no firearms or weapons stored in the home.

At 12:57 p.m. smoke and carbon monoxide detectors were tested and are operable. The valve on the required 3: A40 BC fire extinguisher indicates fully charged and was serviced on 07/05/23, per the attached service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually.

The isolation area for sick children waiting to be picked up is in bedroom #1 with supervision.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

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 advised licensee to check with the American Standard Testing Materials for Playground Guidelines and/or to use the manufactures recommendations for the playground equipment in efforts to be more in line with safety guidelines.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3386
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: BURGUENO FAMILY CHILD CARE
FACILITY NUMBER: 198015668
VISIT DATE: 02/23/2024
NARRATIVE
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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, and 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). LPA observed child 2 (C2) is missing LIC 9227, LIC 282, and the 15-minute infant sleep check. C2 is missing proof of LIC 282.

Licensee’s records were reviewed for approved 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’s Mandated Reporter Training expires on 06/05/24. Licensee’s Pediatric CPR/FA was taken through the National CPR Foundation and expires on 09/29/25. Licensee was advised that the approved Pediatric CPR/FA is from: EMSA, American Red Cross, or American Heart Association. LPA provided Licensee with a copy of the First Aid and CPR child care training program providers.

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

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

Licensee is caring 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-andresources/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 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) 981-3386
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: BURGUENO FAMILY CHILD CARE
FACILITY NUMBER: 198015668
VISIT DATE: 02/23/2024
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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 Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Licensee Elizabeth Burgueno confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

Exit interview conducted and report was reviewed with the Licensee Elizabeth Burgueno.

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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3386
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/23/2024 03:12 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
MONTEREY PARK CC RO, 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: 02/23/2024

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 observation, the licensee did not comply with the section cited above in Licensee does not have the 15 minute documentation sleep check for Child 2 (C2) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Per licensee, she will begin documenting infant sleep every 15 minutes and will submit proof to LPA by POC due date.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in Licensee completed an online Pediatric CPR/FA that is not approved by EMSA, American Red Cross, or American Heart Association which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Per Licensee, she will complete a new Pediatric CPR/FA with an approved provider and will submit proof to LPA by POC 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) 981-3386
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 02/23/2024 03:12 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
MONTEREY PARK CC RO, 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: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in Child 2 (C2) and C4 are missing LIC 282 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Per Licensee, she will have parents of C2 and C4 complete form LIC 282 and will submit proof to LPA by POC due 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 observation, the licensee did not comply with the section cited above in C2 is missing LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Per Licensee, she will have parents of C2 complete form LIC 9227 and will submit proof to LPA by POC 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) 981-3386
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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