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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019948
Report Date: 10/16/2019
Date Signed: 10/16/2019 10:10:12 AM

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:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
198019948
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
10/16/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:09 AM
MET WITH:Maura LopezTIME COMPLETED:
10:15 AM
NARRATIVE
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Annual Random inspection conducted by Licensing Program Analyst (LPA) Jennifer Hua. LPA met with Maura Lopez, Licensee, who guided Analyst on a tour of the facility. Per licensee, there are a total of 3 adults residing in the home and 0 minors. Per licensee, currently, operation hours are Monday to Saturday 6AM - 6PM. Licensee may also provide over night care, but no over night care provided at this time. This is a single story home consists of 4 bedrooms, 2 bathrooms.

Child Care areas were inspected as follows: Living Room, 1 bedroom (left of hallway), hall bathroom, kitchen, dining area and fenced back yard. Areas that are usedaccessible by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating (air conditioner observed). Detergents, cleaning compounds, sharp objects and hazardous items that can pose a danger to children were observed to be inaccessible in the areas designated for children.

Per Licensee, areas off limits to children and parents are: Bedrooms #2, 3 and 4 , garage and front yard.

Per licensee, there are no weapons, firearms, swimming pool or spa on the premises. The backyard is adequately fenced There are age appropriate toys and equipment on the premises. The smoke/carbon monoxide detectors and fire extinguisher (2A 10BC) are in operable condition and is fully charged but has not been serviced annually as required.

-Licensee is current in Pediatric CPR/First Aid. Certificate will expire on 3/23/2021
-Child Care Roster, Disaster Plan, and Children's Records were reviewed.
-Children records and required licensing forms were discussed as well as mandated child abuse reporting and criminal records clearance (finger prints and child abuse clearance) requirement. Licensee complete the Mandated Reporter training on 6/7/18.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019948
VISIT DATE: 10/16/2019
NARRATIVE
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The following was discussed: Individuals who are 18 years of age or older living/working in the home must be finger print cleared prior to being on the premise. Individuals within one month of their 18th birthday must be fingerprinted immediately. If an individual has a clearance with the Department a criminal record clearance may be transferred. LIC 9182 Criminal Background Clearance Transfer Request may be used.

Rooms that are off-limits need to be made inaccessible during operating hours. No smoking, No infant walkers, Johnny jumpers, exersaucers, bouncers and any other item that falls into that category, earthquake – fire, disaster drills and safety, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal records, child abuse clearance and criminal records transfer requirements, SIDS, Never Shake A Baby. A Child Care Provider's Guide to Safe Sleep was discussed and provided to Licensee. .

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) 514-0388 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

· Dog(s) and or pets should be isolated from children in care. No pets
· It is recommended that a First Aid kit be available on premises.
Outdoor supervision required at all times. If outdoor area not adequately fenced provider must be with children at all times when outdoors.

Deficiencies cited on attached 809D.
Exit interview was conducted with licensee. Appeals Rights provided and explained.
Site visit notice posted. And Licensee advised to keep notice posted for 30 days.
Web site address to order forms: http://www.dss.cahwnet.gov/cdssweb/On-lineFor_293.htm#l
INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019948
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2019
Section Cited

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Operation of a Family Child Care Home. Each family child care home shall conduct fire drills and disaster drills at least once every six months and document the date and time of each drills. The requirement is not met as evidenced by: Drill log indicates drills have not been conducted every 6 months. This poses a potential risk to the health and safety of children in care.
Type B
10/21/2019
Section Cited

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Operation of a Family Child Care Home. A file of affidavits signed by each parent with a child enrolled in the home shall be maintainted. The requirement is not met as evidenced by: LPA observed child #1 - #5, form not in file/not signed. This poses a potential risk to the health and safety of children in care.
Type B
10/21/2019
Section Cited

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Operation of a Family Child Care Home. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal. The requirement is not met as evidenced by: LPA observed fire extinguisher is fully charged but has not been serviced annually. This poses a potential risk to the health & safety of children
Type B
11/15/2019
Section Cited

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Immunization Requirements. Effective 9/1/16, all individuals who provide care and supervision to children are required to obtain immunizations for Pertussis, Measles and Influenza. The requirement is not met as evidenced by: Assistant #1 lack measles and flu record. This poses a potential risk to the health and safety of children in care.
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) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3