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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019677
Report Date: 01/11/2023
Date Signed: 01/24/2023 08:01:58 AM


Document Has Been Signed on 01/24/2023 08:01 AM - 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 CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:MARTINEZ FAMILY CHILD CAREFACILITY NUMBER:
198019677
ADMINISTRATOR:LORENA MARTINEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 427-4708
CITY:LOS ANGELESSTATE: CAZIP CODE:
90011
CAPACITY:14CENSUS: 2DATE:
01/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lorena Martinez, LicenseeTIME COMPLETED:
03:44 PM
NARRATIVE
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On Wednesday, January 11, 2023 at 12:45 pm., Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with Licensee Lorena Martinez who guided LPA Rivera on a tour of the facility.

During the inspection, 2 infants were present. Family members residing in the home has been discussed with licensee and have obtained a criminal record clearance or exemption. Operating hours are Monday to Sunday 8:00 a.m. to 7:00 p.m and care for children ages 0 to 13 years.

This facility is a one-story home that consists of three bedrooms, two full bathrooms, kitchen, living room, and front yard and backyard (fenced and gated). Areas that are accessible to children and identified on the facility sketch were inspected by LPA Rivera; living room, two children bedrooms, and two bathrooms, kitchen, and backyard. Areas off limits to children include- front yard and master bedroom.

At approximately 12:45 p.m., LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Rivera observed ceiling fans, no heater and the wall heater is off and LPA observed gas company red tag. LPA observed the furniture and children materials to be in good condition and age appropriate.

At approximately 12:56 p.m, LPA Rivera entered the restrooms and observed toilets, hand washing sinks, and soap. LPA did not observe any hazards and observed the restroom and hand washing sink area to be in good condition.

At approximately 1:07 p.m., LPA entered the kitchen and observed the cleaning compounds items stored inside the bottom kitchen sink cabinet with a child proof lock making it inaccessible for children to open. Knives and sharp objects, LPA observed the items stored inside the top kitchen cabinet with child proof lock making it inaccessible for children to open. For drinking water, LPA observed water bottles. Licensee is currently enrolled with California Adult Child Care Food Program. Currently the facility does not have any children with food allergies.

SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
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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Document Has Been Signed on 01/24/2023 08:01 AM - 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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Rivera observation the licensee did not comply with the section cited above in not having a heater (ventilation) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Licensee stated she is going to purchase a portable/ child proof heater by this weekend 1/14/23.
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Rivera observation the licensee did not comply with the section cited above in observing bug stop and gallon of soap accessible to childre which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Licensee stated she will removed the items this evening and place them in the grey closed and locked grey shed.
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: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2023 08:01 AM - 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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Rivera observation and record review the licensee did not comply with the section cited above in not having the safe sleep log for child #1 and #2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Licensee stated she has the safe sleep logs and will start documenting tomorrow 1/12/23.
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 LPA Rivera observation and record review, the licensee did not comply with the section cited above in not having her immunization record TDAP, MMR, Influenza or Influenza Declination which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Licensee stated she will call her Dr, and obtain copies of her immunization
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: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2023 08:01 AM - 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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)(2)
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. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Rivera observation and record review, the licensee did not comply with the section cited above in not having the LIC 9227 Safe Sleep Plan completed by the parents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Licensee stated she will be providing the parents the LIC 9227 Safe Sleep Plan form and have them complete the form during pick up.
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: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019677
VISIT DATE: 01/11/2023
NARRATIVE
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LPA Rivera asked if there are any pets, poisons, firearms, weapons or bodies of water. Licensee stated she does not have pets, no body of waters, no firearms, no weapons or poisons. LPA did not observe, pets, firearms, weapons, nor bodies of water. LPA observed poison(bug stop) . Licensee was advised that if any poisons (ex; drano, rat poison or items with skull hazard symbol), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition must be stored separately.

At approximately 1:15 p.m., LPA Rivera observed the 2A10BC fire extinguisher located in the kitchen and the valve on the green shaded area. LPA informed that the fire extinguisher needs to be replaced or serviced yearly. LPA observed the smoke and carbom monoxide detector in the living room. The detector was tested and is operable. LPA observed the first Aid complete with band aids, gauzes, adhesive bandages and antiseptic wipes and located in the living room. LPA observed the fire/earthquake drill log and last drill conducted on 1/4/2023.

At approximately 1:24 p.m., LPA Rivera inspected the outdoor area used by children for safety, comfort and cleanliness. LPA did not observe any children outdoor play equipment. LPA observed the play equipment inside the wooden shed. LPA observed a grey she closed and locked with a fastener. LPA observed a bug stop next to the grey shed and informed licensee that is a poison and must be placed behind closed locked cabinets. LPA also observed a gallon of soap on next to the side gate. No children were outside playing. LPA observed the side yard fenced, gated, and closed with a self-latch keypad lock.

LPA observed licensee Pediatric First Aid/ CPR certification dated 4/18/21, Health and Safety (8 hour) certification dated 5/13/22 and the AB 1207 Child Abuse Mandated Reporting training on 3/12/21. Licensee did not have proof of immunization against Pertussis, MMR and Influenza. Licensee was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

At approximately 1:45 p.m., LPA reviewed child #1 file and file is missing Safe Sleep Plan and Safe Sleep log and child #2 missing immunization records, Safe Sleep Plan and Safe Sleep log. Licensee does not have record of her TDAP, MMR and influenza or influenza declination.

SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019677
VISIT DATE: 01/11/2023
NARRATIVE
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Safe Sleep: LPA discussed the safe sleep regulations with Licensee Lorena Martinez 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 Lorena of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at also explained to licensee that car seat, stroller are only and only for 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 Rivera also reviewed Sudden Infant Death Syndrome (SIDS), Never Shake A Baby, and Lead Exposure information with licensee. LPA informed car seats are only for transportation, highchair is only and only for feeding and stated items cannot be misused. No smoking, No infant walkers, No Johnny jumpers, No saucer chairs and any other item that falls into this category are not permitted in a family child care facility.



Medication: 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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Currently the facility has not children with or on medication.

Criminal Record Statement: Licensee Lorena Martinez 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.

Licensee has been given five Type B violations and one Technical Violation with due date February 10, 2023.

SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019677
VISIT DATE: 01/11/2023
NARRATIVE
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Type B violations- Child #1 and #2 missing LIC 9227 Safe Sleep Plan and Safe Sleep log, Child #2 missing record of immunization, Licensee missing TDAP, MMR and influenza or influenza declination, fire extinguisher not serviced or purchased within a year, no heater (ventilation), and outdoor gallon of soap and bug stopper accessible to children (no preschool or school age children present during visit). Technical violation missing LIC 610A Emergency Disaster Plan.

A notice of site visit was given and posted and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Licensee Lorena Martinez.

SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7