304205434-5-30-2023-06-CC-RMCN-CSBL8C-20230530083141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304205434
Report Date: 05/26/2023
Date Signed: 05/30/2023 09:47:00 AM

Document Has Been Signed on 05/30/2023 09:47 AM - 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	HOLGUIN, KELLY		FACILITY NUMBER:	304205434
ADMINISTRATOR:	HOLGUIN, KELLY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 963-3307
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92646
CAPACITY:	14	CENSUS: 10	DATE:	05/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Licensee Kelly Holguin		TIME COMPLETED:	05:00 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 annual inspection was conducted at the facility by Licensing Program Analyst (LPA) Romy Castanon and LPA Karen Navar. LPA’s observed Licensee Kelly Holguin and her assistant caring for 10 children total. Seven children were napping when LPA’s arrived. Licensee was operating within the licensed capacity as specified on license. Facility Day care hours are 7:30 AM - 5:30 PM, Monday through Friday. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During today’s inspection, LPA toured the inside and outside areas identified in the facility sketch as accessible to children. Off limits areas are made inaccessible by means of baby safety locks and safety gates. The childcare area consists of the living room (daycare room), hallway restroom, and three bedrooms used for napping. There is also a large backyard for children to play outdoors. Licensee stated the children's primary area is the daycare room (living room). The facility has a fireplace inside the family room that is inaccessible to children. There is a working carbon monoxide, smoke detector, and a fire extinguisher in the home that meet statutory and State Fire Marshall standards. Licensee was informed emergency/fire drills are to be conducted and document. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible in cabinets. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. The home has age-appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service). Licensee stated, they use the backyard for outdoor play, LPA inspected the backyard, and it was found to be in compliance. There are no bodies of water in the facility. Continue to page 2

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Romelia M Castanon	TELEPHONE: (714) 746-8565
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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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Document Has Been Signed on 05/30/2023 09:47 AM - It Cannot Be Edited

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: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with Licensee and record review, the licensee did not comply with the section cited above in regards to documenting 15 minute safe sleep logs for 3 out of 3 children which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Licensee will create sleeping log for all infants in care, as well as, send LPA a weeks worth of completed logs by POC date.

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with Licensee and record review, the licensee did not comply with the section cited above in 2 out of 2 staff did not have a mandated reporter certificate on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Licensee and one staff member will complete training and submit certificates to LPA by POC day.

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 Lopez	TELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Romelia M Castanon	TELEPHONE: (714) 746-8565
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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: HOLGUIN, KELLY	FACILITY NUMBER: 304205434
	VISIT DATE: 05/26/2023

NARRATIVE

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The licensee has a current roster of children in care. Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A) and found to be in compliance.

The licensee Pediatric CPR/First Aid certification expires 08/2023. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. Licensee needs to complete mandated reporter training.

The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training.

LPA provided updated licensing forms and reviewed them with Licensee.
CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.

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SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Romelia M Castanon	TELEPHONE: (714) 746-8565
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 05/26/2023

NARRATIVE

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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.

Important COVID-19 resources and links were provided: COVID-19 Update Guidance Childcare Programs/Providers link: https://files.covid19.ca.gov/pdf/guidance-childcare.pdf CCLD COVID-19 Licensed childcare and facilities and provider FAQs link: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/child-care-licensing/covid-19-child-care-resources/faqs-for-licensed-child-care-facilities-and-providers

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

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.

In the areas that were evaluated, the following deficiencies were observed of the California Code of Regulations, Title 22, Division 12 102425(j) and Health & Safety 1596.8662(b)(1) at the time of the visit.

Exit interview conducted and report was reviewed with the licensee Kelly Holguin. A notice of site visit was given and must remain posted for 30 days. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

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. (End of Report)

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Romelia M Castanon	TELEPHONE: (714) 746-8565
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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