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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243909471
Report Date: 08/21/2019
Date Signed: 08/21/2019 03:20:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:BAEZA, ELSA FAMILY CHILD CAREFACILITY NUMBER:
243909471
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
08/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Elsa Baeza - LicenseeTIME COMPLETED:
03:30 PM
NARRATIVE
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(2) Licensing Program Analyst, Joseph Pacheco, conducted an unannounced Annual/Random inspection today. LPA met with Licensee, Elsa Baeza, toured the home, and census was taken. Staff were spoken to during visit. Licensee is currently providing care to family members only. Licensee is not currently providing care to children from other families. There are no "bodies of water" or firearms in this home. Poisons, cleaning compounds, medications and other hazardous items are inaccessible to children. There is no fireplace. There is a working fire extinguisher, smoke and carbon monoxide detector, and there is adequate heating and ventilation for safety and comfort. There are no stairs in the home. There is a working telephone. Adequate supervision is being provided during this visit. Children are supervised when outside in the backyard play area. Licensee has five dogs that are inaccessible to children by being kept in off-limits areas of the home. Licensee is aware of child safety around pets and accepts responsibility for any action taken by pets. Capacity as specified on the license is being maintained. Licensee was advised on the requirements of maintaining a current LIC 9040 – Child Care Facility Roster. Licensee was also reminded that Fire Drills are required to be conducted at least once every six months and to document the time and who was present. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. Licensee did not have a current First Aid/CPR card from an approved instructor. Licensee was provided with information on how to complete AB 1207 Mandated Reporter training. Immunization’s for staff was reviewed and verified.

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



CONTINUED ON 809-C
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: BAEZA, ELSA FAMILY CHILD CARE
FACILITY NUMBER: 243909471
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2019
Section Cited
CCR
102416(c)
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Personnel Requirements. 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 was not met as evidenced by:
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Licensee to provide proof of paid enrollment to an approved First Aid/CPR instructor to LPA by 9/4/19.
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LPA observation of no current First Aid/CPR card from an approved provider. This item poses a potential risk to the health, safety, or Personal rights of children in care.
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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: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019
LIC809 (FAS) - (06/04)
Page: 3 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: BAEZA, ELSA FAMILY CHILD CARE
FACILITY NUMBER: 243909471
VISIT DATE: 08/21/2019
NARRATIVE
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An exit interview was conducted with Licensee. LPA provided Licensee with information regarding providing incidental medical services to children, the CDSS Provider Information Notices (PINs) communication system, and some important resources and information links offered on the CDSS website. Lead safety information was provided in accordance with AB 2370, Chapter 676, Statues of 2018.

Hours of operation are Monday through Friday, 6:00am – 6:00pm.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, the following deficiencies were observed today (see LIC809-D):

THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3