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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304205434
Report Date: 07/22/2019
Date Signed: 07/22/2019 04:29:43 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:HOLGUIN, KELLYFACILITY NUMBER:
304205434
ADMINISTRATOR:HOLGUIN, KELLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 963-3307
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:14CENSUS: 8DATE:
07/22/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kelly Holguin, LicenseeTIME COMPLETED:
04:45 PM
NARRATIVE
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An inspection was conducted at the facility by Licensing Program Analyst (LPA) Port. A review of adult records indicates that all facility residents, staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently 2 adults (including the licensee) living in the home.

During today’s inspection the home and grounds were toured. The licensee was not operating within the maximum capacity of a large family child care home license. There were 5 infants in care, and 3 preschool age children being cared for by the licensee and her husband (assistant) Gerard Holguin. The maximum number of infants (children under age 2) that can be cared is four. Operating hours are 7:30 AM to 5:30 PM, Monday through Friday.

The floor plan was verified. Off limits areas are made inaccessible by means of baby gates and door locks. The garage is off limits. The children use the backyard as the outdoor play area, and it is completely fenced. The outdoor play area is free from hazards. There are no bodies of water on the premises. There is a fireplace in the family room screened by a fire place cover and inaccessible to children in care. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children.The licensee stated poisonous items are not stored on site, and none were observed during today's inspection. LPA observed an unoccupied baby walker in the dining room which licensee moved to the patio. Baby walkers are not permitted on the premises of a family child care home.There is a working carbon monoxide detector, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's visit. LPA verified there is a working telephone (land line) service at the facility.

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(Continued on Page 2)
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy PortTELEPHONE: (714) 703-2815
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2019
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 6
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: HOLGUIN, KELLY
FACILITY NUMBER: 304205434
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2019
Section Cited
HSC
1596.8662
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Mandated Reporter Training. Beginning on January 1, 2018, this law requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years...This requirement was not met as evidenced by:
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LPA provided licensee with written instructions for mandated reporter training from the Fall 2017 Quarterly Update. The licensee stated she and assistant will complete mandated reporter training and a copy of the completion certificate will be sent to our office by the due date of 08/13/2019.
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The licensee stated she was not aware of this requirement. The licensee and assistant present today do not have proof of completion of mandated reporter training. This poses a potential safety risk to children in care.
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Type B
08/13/2019
Section Cited
CCR
102417(g)(10)
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Operation of a Family Child Care Home 102417(g)(10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Section 1596.846(b) and (c). This requirement was not met as evidenced by:
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The licensee stated she will remove the baby walker and not utilize it for child care. The licensee understands baby walkers are not allowed. Written acknowledgment will be sent to the licensing office by the due date of 08/13/2019. LPA provided licensee with a copy of prohibited items.
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LPA observed an unoccupied baby walker in the dining room which licensee moved to the patio. Baby walkers are not permitted on the premises of a family child care home. This poses a potential safety risk to 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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy PortTELEPHONE: (714) 703-2815
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2019
LIC809 (FAS) - (06/04)
Page: 6 of 6
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: HOLGUIN, KELLY
FACILITY NUMBER: 304205434
VISIT DATE: 07/22/2019
NARRATIVE
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The licensee understands she must be present in the home and must ensure children that children in care are supervised at all times. The licensee stated children are not left in parked vehicles. The licensee understands when temporarily absent from the home, she must arrange for a qualified substitute adult to care for and supervise children in her absence. The substitute adult must have the required criminal record and child abuse index clearances, SB 792 immunizations, mandated reporter training, and valid pediatric first aid/CPR certifications.

The licensee's pediatric CPR/First Aid certification is current, which expires 08/2020. The licensee did not have an updated children's roster during today's inspection. Children's records for children present during today’s inspection were reviewed for a completed Identification and Emergency Card, four of the eight records reviewed were missing the LIC 700.

Beginning March 31, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years, per A.B. 1207. The licensee and assistant do not have proof of compliance as specified in A.B. 1207.

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 .

Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov A hard copy of the Summer 2019 Child Care Quarterly Update was provided to the licensee.

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy PortTELEPHONE: (714) 703-2815
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2019
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: HOLGUIN, KELLY
FACILITY NUMBER: 304205434
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2019
Section Cited
CCR
102416.5(d)(1)
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Staffing Ratio and Capacity 102416(d)(1) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home.... shall be either:(1)Twelve children, no more than four of whom may be infants. This requirement was not met as evidenced by:
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The licensee stated she will disenroll one child and send confirmation to the licensing office by the due date of 07/23/2019. LPA provided licensee with printout of staffing and ratio for large family child care home.
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During today's inspection LPA observed 5 infants (under the age of 24 months) being cared for by the licensee and the licensee's spouse. This poses an immediate safety risk to 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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy PortTELEPHONE: (714) 703-2815
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2019
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: HOLGUIN, KELLY
FACILITY NUMBER: 304205434
VISIT DATE: 07/22/2019
NARRATIVE
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A hard copy of the 2016 “A Child Care Providers Guide to Safe Sleep” and Department of Social Services Lead Information Brochure were explained and provided to the licensee. The following electronic links were also provided:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
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
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: 102416(d)(1) , 102417(g)(10), 102417(g)(8), 102421(b), and Health and Safety Code 1596.8662 (see LIC 809D). This report cites a Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file. Form LIC 9224 was provided to the licensee.

Inspection, report review and exit interview was conducted. Notice of Site Visit was posted during the visit. 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. Appeal rights provided and explained. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy PortTELEPHONE: (714) 703-2815
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2019
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: HOLGUIN, KELLY
FACILITY NUMBER: 304205434
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2019
Section Cited
CCR
102417(g)(8)
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Operation of Family Care. Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met by evidenced by:
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This licensee stated she will complete a roster a send a completed copy to the licensing office by the due date of 08/13/2019.
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There was not a completed roster available during today's inspection. This is a potential safety risk to children in care.
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Type B
08/13/2019
Section Cited
CCR
102421(b)
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Child's Records 102421(b) The licensee shall maintain, in each child's record, a copy of the emergency information card required in Section 102417(g)(7). This requirement was not met as evidenced by:
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The licensee stated she will have the parent's complete the LIC 700 and send a completed copy to our office by the due date of 08/13/2019.
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Four of the eight children's records reviewed did not have a completed LIC 700 on file. This poses a potential safety risk to 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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Wendy PortTELEPHONE: (714) 703-2815
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2019
LIC809 (FAS) - (06/04)
Page: 5 of 6