198020993-5-31-2022-33-CC-BBEL-CEXU7J-20220531152000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020993
Report Date: 05/31/2022
Date Signed: 05/31/2022 03:20:18 PM

Document Has Been Signed on 05/31/2022 03:20 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:	JIMENEZ FAMILY CHILD CARE		FACILITY NUMBER:	198020993
ADMINISTRATOR:	MARIA LOURDES JIMENEZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 846-7252
CITY:	POMONA	STATE: CA	ZIP CODE:	91766
CAPACITY:	14	CENSUS: 0	DATE:	05/31/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Applicant Maria Jimenez		TIME COMPLETED:	03:30 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	An announced, in-person Prelicensing inspection was conducted on this date by Licensing Program Analyst (LPA) Emiko Bell. Upon arrival, LPA was greeted and let into the residence by Applicant Maria Jimenez, to whom the purpose of the inspection was announced. As a precautionary measure against COVID-19, applicant and LPA wore face coverings the duration of the inspection. Census: Upon LPA's arrival, there were three adults present and one arrived during the inspection. At 09:40 am, LPA began the tour of the premises. At 11:15 am, LPA finished the tour and began the report. LPA provided applicant with the facility forms, the forms required for the children's files and the required postings, as well as the self-assessment checklist and postings which were required for the RAST inspections. Applicant's proposed days and hours of operation are Monday-Friday, 07:00 am-05:00 pm. At this time, applicant is proposing to care for children ages 0 to 5 years old. This is a single-story, single family residence with three bedrooms and two bathrooms. All adults over the age of 18 who live in the residence have Criminal Background Clearance and have been associated.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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: JIMENEZ FAMILY CHILD CARE	FACILITY NUMBER: 198020993
	VISIT DATE: 05/31/2022

NARRATIVE

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All areas identified on the facility sketches were inspected in the following order: (outdoors) the backyard and the detached garage and (indoors): the laundry area/room, the kitchen, the dining room, the living room, room #1, room #2, bathroom #1, and rooms #3 -4

The areas which have been designated as off-limits are: (indoors): room #1, room #2, bathroom #1, the kitchen, the dining room, the living room and (outdoors): the garage, the storage area and the front of the side yard where the dogs are.

Physical Plant: The residence was inspected for safety, comfort, cleanliness, telephone service (applicant only has a cell phone); heating and ventilation (there is a ceiling fan in each bedroom and central heating and air-conditioning); inaccessibility to poisons (it is stored in lockers in an off-limits area of the backyard); detergents and cleaning compounds (they are stored in the cabinet above the washer and dryer); medicine (stored in a container in a kitchen cabinet which contains a childproof latch); and other hazardous items that can pose a danger to children. Knives are kept in one of the kitchen drawers which is locked with a childproof latch.

Toys and napping equipment: There are age-appropriate toys and napping equipment (there is one play yard and one mat) on the premises. Applicant stated she will purchase more toys and napping equipment as necessary.

Parent Board: Applicant's Parent Board is on the wall to the right of the entryway, behind the door.

Rooms 3 and 4 will be used as the daycare rooms. Applicant will have parents enter on the side of the residence, through the backyard, which directly leads to room #4.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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: JIMENEZ FAMILY CHILD CARE	FACILITY NUMBER: 198020993
	VISIT DATE: 05/31/2022

NARRATIVE

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Pets: Applicant currently has two dogs, that are in the side yard. Applicant was advised to keep their vaccinations current and accessible.

Fire safety: There are six smoke detectors on the premises; all were tested and are operable. There is one in each bedroom, in the living room, and one in the hallway. In addition, there is a separate carbon monoxide detector in rooms #3 and #4 the hallway, which were tested and iare operable. There is one fire extinguisher mounted on a wall in the kitchen counter; it was purchased 02/22 and is size 3-A:40-B:C.

Fire clearance was granted on 05/24/22.

Transportation: Applicant stated that she will provide transportation. Applicant understands that her vehicle may be inspected during licensing inspections.

Firearms: Applicant stated that there are currently no weapons or firearms on the premises.

Incidental Medical Services: This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes 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

There is one First Aid Kit; it is kept in the closet in room 4. Applicant also has an Emergency backpack which is kept in the closet in room 4.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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: JIMENEZ FAMILY CHILD CARE	FACILITY NUMBER: 198020993
	VISIT DATE: 05/31/2022

NARRATIVE

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Applicant Maria Jimenez was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

No smoking; no infant walkers, Johnny jumpers, exersaucers and any other items that fall into that category; earthquake & fire disaster drills and safety; posting requirements; children's records requirements; mandated child abuse and injury/death reporting; criminal records, child abuse clearance, and criminal records transfer requirements.

LPA discussed the safe sleep regulations with applicant Maria Jimenez 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 applicant Maria JImenez of the importance of checking for recalled infant defices on the United States Consumer Product Safetey 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 reviewed with Applicant Maria Jimenez the LIC 311D Forms/Records To Keep In Your Family Child Care Home; children's forms/records, facility forms/records, and information to be posted.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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: JIMENEZ FAMILY CHILD CARE	FACILITY NUMBER: 198020993
	VISIT DATE: 05/31/2022

NARRATIVE

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Paperwork: Applicant provided a mortgage statement and her California driver's license as verification of control of property. Applicant completed online FCCH orientation on 01/25/22.
Applicant completed an EMSA-approved Preventative Health and Safety course (which includes the 2016 nutrition requirement and the 2020 lead requirement) on 02/02/2022. Applicant's pediatric First Aid/CPR were issued by an EMSA- certified provider and expires 02/24. Applicant completed the Mandated Reporter Training on 11/12/20 (Child Care Providers). Applicant provided verification of TB clearance and MMR and TDAP and influenza immunizations.

Applicant has been reminded of the following:
*Fire and earthquake drills to be conducted every six months (for small FCCH) and monthly (for large FCCH.)
*Outdoor supervision is required at all times. If the outdoor area is not adequately fenced, the provider must be with the children at all times when outdoors. Licensee's initials ( ).

Exit interview conducted and report was reviewed with Applicant Maria Jimenez.

Community Care Licensing Division (CCLD) regularly send information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PINs), Program Quarterly Update Newsletters and other important information communication platforms.

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.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC809 (FAS) - (06/04)

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