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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304206439
Report Date: 01/28/2020
Date Signed: 01/28/2020 03:01:51 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:DUENEZ, KARLAFACILITY NUMBER:
304206439
ADMINISTRATOR:DUENEZ, KARLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 697-7329
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:14CENSUS: 12DATE:
01/28/2020
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Karla DuenezTIME COMPLETED:
03:30 PM
NARRATIVE
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An Unannounced Annual inspection was conducted at the facility by Licensing Program Analyst (LPA) Joel Enciso . LPA Enciso observed licensee and her assistant Ana Angulo caring for 12 children; which included 4 infants, 8 preschool children. Licensee was operating within the licensed capacity as specified on the license. Licensee stated that there are currently 4 adults (including the licensee) and 1 minor children living in the facility. Day care operating hours are 7am- 5:30pm Monday- Friday. A review of the Facility Personnel Report Summary on this date indicated that 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 Enciso toured the facility with the licensee the inside and outside areas defined in the facility sketch as accessible to children. The floor plan was verified as a single one story home with 3 bedrooms and 2 restrooms of which only the living room, dining room 2 bedroom, and 1 bathroom are made accessible to children.

Off limits areas were made inaccessible by means of child proof door knob locks. There was a working carbon monoxide, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored and inaccessible by means top shelf. No poisons or other items were observed which could pose a danger to children by LPA Enciso. Sharp knives and other sharp utensils were located in the kitchen and were all inaccessible and located on top of the refrigerator.

Licensee stated there were no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. No fireplace was observed, and licensee stated home has a central heating and cooling system.

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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Joel EncisoTELEPHONE: (714) 296-6577
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2020
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: DUENEZ, KARLA
FACILITY NUMBER: 304206439
VISIT DATE: 01/28/2020
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During today’s inspection LPA Enciso verified a working telephone service via cellular phone.
The licensee was reminded that if a cell phone is only used, it must remain on the premises always during hours of operation. There were no bodies of water on the premises. The home had age appropriate toys for the ages served and the children were observed to have safe, healthful, and comfortable accommodations, furnishings, and equipment

The licensee had a current roster of children in care. Children’s records for children present during LPA Enciso’s inspection were reviewed for: children’s immunizations on the California School Immunizations Card (CDPH 286), a signed copy of the Family Child Care Home Notification of Parents’ Rights (LIC 995a) and the emergency information card that contains all the information specified by regulation (LIC 700) were all found to be in compliance.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against Influenza, Diphteria, Tetanus, Pertussis (Dtap), Measles, Mumps, Rubella (MMR) and Tuberculosis (PPD).
Proof of immunization against Dtap, MMR and a written declination for influenza were reviewed. Tuberculosis test was not in compliance at the time of the visit for Assistant and 1 adult living in home. Licensee stated will obtain proof and submit corrections to LPA Enciso

Mandated Certificate was verified for Licensee and Assistant. 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. The both licensee and assistant’s Pediatric CPR/First Aid certification expire 10/26/21.

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
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Joel EncisoTELEPHONE: (714) 296-6577
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2020
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: DUENEZ, KARLA
FACILITY NUMBER: 304206439
VISIT DATE: 01/28/2020
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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.



A hard copy of the Spring 2019 Child Care Quarterly Update was provided to the licensee. A hard copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee in English. 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

LPA reviewed with licensee the following safe sleep best practices:
· 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.

A copy of the California Department of Social Services Lead Information Brochure was also explained and provided to the licensee.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Joel EncisoTELEPHONE: (714) 296-6577
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2020
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: DUENEZ, KARLA
FACILITY NUMBER: 304206439
VISIT DATE: 01/28/2020
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The following were discussed with the licensee: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to their presence in the facility. Individuals within one month of their 18th birthday must be fingerprinted immediately. No smoking, no infant walkers, baby bouncers, Johnny Jumpers, exersaucer or any other similar items that fall into that category are allowed in the facility. Disaster drills, posting requirements, children record, mandated child abuse and injury/ death reporting, and criminal records clearances/exemption transfer requests. LPA emphasized on the importance of reporting Unusual Incident Reports (UIR) or child absences that threaten the physical, emotional health or safety of any child to the Licensing Officer of the Day within 24 hours to 714-703-2800. Licensee was also advised to complete the form (LIC 624B) within seven days by faxing the form to (714)703-2831 after the Unusual Incident Report is called in to the Regional Office. Furthermore, Licensee was advised to contact Reginal Licensing Office for any changes to the hours and days of operation, changes or modification to the facility or changes to on/off limit areas.
LPA Enciso reviewed Disaster Preparedness/Fire drills (documented every 6 months), posting requirements which include but not limited to Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9141), Parents Rights (PUB 394) and Facility License were observed and in compliance.The licensee understands she must be present in the facility and must ensure children in care are always supervised and never left 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. The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division were observed, discussed and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: Health and Safety 1597.622 (a)(1).

Notice of Site Visit was posted during the visit. Licensee 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. End of Report.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Joel EncisoTELEPHONE: (714) 296-6577
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2020
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: DUENEZ, KARLA
FACILITY NUMBER: 304206439
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/28/2020
Section Cited

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Immunization's. Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been TB tested and immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement was not met as evidenced by:
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Based on records review and licensee interview, The licensee had no proof of Tuberculosis for assistant and 1 adult living in home.
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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Joel EncisoTELEPHONE: (714) 296-6577
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2020
LIC809 (FAS) - (06/04)
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