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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304205231
Report Date: 10/17/2019
Date Signed: 10/17/2019 04:17:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MORA, KIMBERLYFACILITY NUMBER:
304205231
ADMINISTRATOR:MORA, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 693-0620
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY:14CENSUS: 5DATE:
10/17/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Kimberly Mora-LicenseeTIME COMPLETED:
04:30 PM
NARRATIVE
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An unannounced Annual/Random inspection of the facility was conducted by Licensing Program Analyst (LPA) Andrea Taylor toured areas of the home accessible to the children. The census included 5 daycare children. Also present in the home at the time of inspection Licensee's husband and adult son who have clearances. A review of family member/staff records on this date indicates that all family members and/or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

LPA observed current EMSA approved CPR and First Aid certificates (exp:8/21), posted Parent's Rights and current disaster plan. Fireplace contains a screen. Fire extinguisher, carbon monoxide alarm and smoke detector meet regulations. All sharp utensils and cleaning products are stored up high and latched or locked which are inaccessible to children in care. Fire drill log was observed. Medications are stored up high and inaccessible to children in care. Toys and outdoor play equipment age appropriate for the ages served are located here. The backyard is fenced. LPA reminded the licensee that they must report any major changes or alterations to Licensing Office.

Five children’s file were reviewed. Notification of parents’ rights, Parent notification additional children in care, Identification and Emergency information, Consent for emergency medical treatment.

Licensee was reminded that licensee shall be present at facility and ensure that children in care are supervised at all times. Licensee must make sure that a substitute adult cares for the children when licensee is temporarily absent. The licensee was also reminded that no child shall be left alone in a parked vehicle at any time.

No deficiency cited during today's inspection. In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Andrea TaylorTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MORA, KIMBERLY
FACILITY NUMBER: 304205231
VISIT DATE: 10/17/2019
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Exit interview was conducted. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.


A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative.
English: https//www.cdph.ca.gov/programs/SIDS/Doucments/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Doucments/ChildCareProvSleepSPAN2011.pdf

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials


· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Andrea TaylorTELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2019
LIC809 (FAS) - (06/04)
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