198020026-9-10-2019-33-CC-AJLO-BFVRQA-20190910131312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020026
Report Date: 09/10/2019
Date Signed: 09/10/2019 01:13:20 PM

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:	PEREYRA FAMILY CHILD CARE		FACILITY NUMBER:	198020026
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 3	DATE:	09/10/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Gabriela Pereyra, Licensee		TIME COMPLETED:	01:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Visit Conducted in Spanish An unannounced Annual Random Inspection was conducted by Licensing Program Analyst (LPA) A. Lucero. LPA met with licensee Gabriela Pereyra who guided LPA on a tour of the facility. This is a single story, two bedroom, one bathroom home. Currently residing in the home are two adults (Licensee and spouse) and one minor. Present at the time of inspection was licensee's spouse, no other adults were present. Licensee is also requesting a change in capacity from a Small Family Child Care Home to a Large Family Child Care Home. LPA received the Fire Clearance (STD 850) on 08/07/2019 granting the capacity increase. Areas accessible to children were inspected as follows: Living room, dining area, one bedroom, one bathroom, and back yard. Areas off limits include: Kitchen (except when passing to go outside to play or eating), front yard, licensee's bedroom, detached garage located in back yard. Licensee states that there are no weapons or firearms on the premises. LPA did not observe swimming pools or spas on the premises. The backyard is adequately fenced. There are age appropriate toys and equipment on the premises. The smoke detectors and carbon monoxide detectors are present in the facility, but were not tested as children present were napping. Fire extinguisher was present in the home. —CPR Card valid until: 11/10/2020 —Child Care Roster, Disaster Plan, and Children's Records were reviewed and discussed. —Children records and required licensing forms were discussed as well as mandated child abuse reporting and criminal record clearance requirement.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2019

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: PEREYRA FAMILY CHILD CARE	FACILITY NUMBER: 198020026
	VISIT DATE: 09/10/2019

NARRATIVE

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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

The following was discussed with the Licensee:

Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

In the absence of the Licensee, a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.

A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License shall be terminated.

The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and Carbon Monoxide detectors should be checked and batteries replaced as needed. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Fire and safety drills must be performed every six months and documented for review by the Department. Smoking is prohibited in a family child care home. Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2019

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: PEREYRA FAMILY CHILD CARE	FACILITY NUMBER: 198020026
	VISIT DATE: 09/10/2019

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Baby walkers, saucer chairs, bouncers or any similar items are prohibited. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed. LPA provided a complete packet of the Provider Information Network (PIN) 10-02-CCP (SP) dated February 20, 2019 regarding Safe Sleep Awareness Campaign during today’s inspection.

All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

· Dog(s) and/or pets should be isolated from children in care.
· It is recommended that First-Aid kits 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.

These forms may also be downloaded from our website: www.ccld.ca.gov

There were no deficiencies cited during today's visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1

LPA will submit application for approval of a Large Family Child Care Home capacity of 14.

Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty.

Exit interview, copy of report was given. Appeal rights were issued and discussed.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2019

LIC809 (FAS) - (06/04)

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