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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300450
Report Date: 05/09/2019
Date Signed: 05/09/2019 03:31:33 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:LOPEZ, ROSA AMALIAFACILITY NUMBER:
304300450
ADMINISTRATOR:LOPEZ, ROSA AMALIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 537-8602
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:14CENSUS: 8DATE:
05/09/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee's Assistant Sarah LopezTIME COMPLETED:
04:00 PM
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Upon arrival, Licensing Program Analysts (LPAs) Ho & Quinto met with licensees' daughter, Sarah Lopez and toured facility inside and outside. LPA observed 3 infants and 5 preschool age children napping in the day care area. The facility was within licensed capacity and the required ratio. Also, present assisting with the day care was licensee’s assistant, Francisca Pliego. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee arrived home at 3pm to greet LPAs. The home is a separate building from the home day care which is located to the right side of the main house, through the two side gates. Licensee stated OFF LIMITS areas include: the entire main front house including all bedrooms, bathrooms in the main part of the house, garage, left side of backyard. Day care is operating only in the back room on the right side of the back house. Family members residing at facility are 4 adults and no children. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Per Licensee there are no weapons, firearms in the facility at this time. No *swimming pool, spa or other bodies of water observed on the premises. There are age appropriate toys and equipment on the premises. The required fire extinguisher (2A10BC), carbon monoxide, and smoke detectors are in operable condition. Facility roster, disaster drill, and licensee’s required immunization (MMR, TDAP, FLU) were available for review. The licensee was reminded that must present at facility and ensure that children are properly cared for and supervised at all times. The 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. All day-care activities take place in the family room and living room. Children are able to have outside play in the enclosed backyard. Licensee and assistant are current with Pediatric CPR and First Aid and both valid until 7/20/20.
The licensee does not provide Incident Medical Services.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
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 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: LOPEZ, ROSA AMALIA
FACILITY NUMBER: 304300450
VISIT DATE: 05/09/2019
NARRATIVE
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The following were discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to presence in the facility. Individuals within one month of their 18th birthday must be fingerprinted immediately. No smoking, no infant walkers, No Johnny jumpers, no exersaucer or any other similar items that fall into that category are allowed in the facility. Disaster drills, posting requirements, children records, mandated child abuse and injury/ death reporting, and criminal records clearances/exemption transfer requests, SIDS and Never Shake a Baby.

Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov

Licensee was provided the link to take the Mandated Reporter training through the Department website at http://childcare.mandatedreporterca.com/

After a tour of the home and review children and staff's records, the following deficiencies were observed and cited in accordance with Title 22, Division 12, Chapter 3 of Family Child Care Homes. Please refer to attached 809D for documentation of deficiencies.

During exit interview, “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.” Notice of Site Visit was posted. Licensee was informed to keep the Notice of Site Visit posted for 30 days during the daycare hours or $100 civil penalty will be assessed.

The facility representative was informed that the CRIMINAL RECORD STATEMENT (LIC 508) has been updated, and the facility must now use the new form with revised date 7/15. The facility representative was also informed that the LIC 508 must be submitted with all Criminal Background Clearance Transfer Request (LIC9182). The facility representative was informed that Licensing Updates are available at www.ccld.ca.gov
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
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: LOPEZ, ROSA AMALIA
FACILITY NUMBER: 304300450
VISIT DATE: 05/09/2019
NARRATIVE
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Information on the additional nutrition training, immunization requirements for children, and Health Schools Act
(http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org and a copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided.

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.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
LIC809 (FAS) - (06/04)
Page: 4 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: LOPEZ, ROSA AMALIA
FACILITY NUMBER: 304300450
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2019
Section Cited
HSC
1596.866(b)
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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child 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
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Licensee stated she and assistant will take the training and send proof to LPA by 6/6/19.
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following the date on which he or she completed the initial mandated reporter training.This requirement was not met as evidence based on record review. During today's inspection, licensees and assistant files were reviewed. Licensee and staff 2 files did not have proof of training. This poses a potential danger to the health and safety of the children.
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Type B
05/29/2019
Section Cited
CCR
102369 :
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Application for Initial License: Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care. This requirement was not met as evidence based on record review. During today's inspection, staff #2 was missing
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Licensee stated she will send proof of tuberculosis clearnce for staff 2 to LPA by 5/29/19.
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the tuberculosis clearance. This poses a potential danger to the health and safety of the children.
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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: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4