274450226-6-29-2022-07-CC-SCES-CFUSRT-20220629140652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 274450226
Report Date: 06/29/2022
Date Signed: 06/29/2022 02:07:48 PM

Document Has Been Signed on 06/29/2022 02:07 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	ARREOLA, ANA		FACILITY NUMBER:	274450226
ADMINISTRATOR:	ANA ARREOLA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 675-3816
CITY:	GONZALES	STATE: CA	ZIP CODE:	93926
CAPACITY:	14	CENSUS: 5	DATE:	06/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Ana Arreola		TIME COMPLETED:	02:15 PM

NARRATIVE

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On 06/29/2022 at 12:10 PM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Ana Arreola, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee with 5 children: three preschool, one infant and one school age. Adults living in the home are licensee and their daughter. Days and hours of operation are Monday through Friday 5:30 AM to 5:30 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 06/28/2022 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. Licensee 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.

LPA inspected inside and outside of the home. LPA observed a blocked fireplace, no wall heater, gated stairs, and no bodies of water. Licensee stated there are no weapons and no pets. LPA observed a 3A40BC fire extinguisher that was serviced on 01/31/2022. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored in the garage and on top of the refrigerator. Backyard is fenced. Off limit areas: second floor, living room, kitchen, dinning room, one room on the first floor, left side of yard that has a in-law unit, shed, and left and right side yards.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to their license with an aid. Licensee stated they do not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.

Continues on report dated 06/29/2022 pg. 1/2

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ARREOLA, ANA	FACILITY NUMBER: 274450226
	VISIT DATE: 06/29/2022

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Continuation of report dated 06/29/2022 pg. 2/2

LPA took a picture of a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 06/01/22. LPA reviewed 6 children’s files and observed all required documentation was in compliance as well as an infant individual sleeping plan (LIC 9227) for each infant under 12 months and a 15 minute check sleep log for infants under 24 months. LPA observed that the Licensee has Mandated Reporter training, training was completed on 03/08/22. Licensee has Pediatric CPR/1^st Aid expiring 02/03/24. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

LPA discussed the safe sleep regulations with licensee 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 of the importance of checking for recalled infant devices on the United States Consumer Product Safety 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

No deficiencies were cited during today's visit. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. Exit interview conducted and report was reviewed in Spanish with the licensee, Ana Arreola. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC809 (FAS) - (06/04)

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