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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300450
Report Date: 05/15/2023
Date Signed: 05/15/2023 11:00:04 AM


Document Has Been Signed on 05/15/2023 11:00 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:LOPEZ, ROSA AMALIAFACILITY NUMBER:
304300450
ADMINISTRATOR:LOPEZ, ROSA AMALIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 809-6994
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:14CENSUS: 7DATE:
05/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:12 AM
MET WITH:Rosa Lopez, LicenseeTIME COMPLETED:
11:45 AM
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LIcensing Program Analyst, (LPA) P Rivas conducted an unannounced annual inspection and was assisted by licensee Rosa Lopez. Also present in the facility were two assistants and four children (1 of which was an infant). During visit 3 other children arrived (one of which was an infant).
Hours of Operation are M-F 7:00am to 6:00pm.
A review of the Facility Personnel Report Summary via Guardian was conducted on 05/15/2023 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The licensee, Ms. Lopez was reminded that all adults 18 and over, 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 family day 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.
During today’s inspection, LPA toured the inside and outside areas identified in the facility sketch as accessible to childcare children. 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 which includes the licensee. The following was observed and reviewed during this inspection. There are no bodies of water on the premises. The Licensee was reminded that full supervision is required at all times to ensure children do not have access to the off-limit areas. The off-limit areas are kept closed during day care hours as stated by licensee.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
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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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: 05/15/2023
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There are 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 inaccessible to children.
There are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. The facility has age appropriate toys for the ages served. LPA verified there is a cellular phone and understands the cell phone needs to be at the facility during operating hours. The licensee does have a current roster of children in care.
The licensee's Pediatric CPR/First Aid certification expires on 06/06/2024. 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, pertussis, and measles. Three staff files reviewed had immunizations as required.
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. Three out of three files reviewed did not have a current Mandated Reporter Training; Training expired 02/19/2021. A citation will be issued under H.&S Code 1596.8662
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP: Best Practices Related to the Provision of Incidental Medical Services in Child Care Centers and Family Child Care Homes. 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

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.CCLD website www.cdss.ca.gov

Cont. page 3

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
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: LOPEZ, ROSA AMALIA
FACILITY NUMBER: 304300450
VISIT DATE: 05/15/2023
NARRATIVE
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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 Child Care Providers Guide to Safe Sleep” was discussed to the licensee.

The following electronic links were also provided: English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.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 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.

LPA reviewed with licensees 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 if 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.

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
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: LOPEZ, ROSA AMALIA
FACILITY NUMBER: 304300450
VISIT DATE: 05/15/2023
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In the areas that were evaluated, The following deficiencies were observed under the California Code of Regulations Title 22 Division 12
102425 Infant Safe Sleep(i)(2)
102425(c) Infant Safe Sleep- Individual Safe Sleep plan
1596.8662(b)(1) Mandated Reporter Training
Child Abuse Mandated Reporter Training (ca.gov)

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/inspection-process.



An exit interview was conducted with licensee, in Spanish with Rosa Lopez. Appeal Rights were explained. The licensee was provided a copy of appeal rights (LIC 9058 01/16) 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. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 05/15/2023 11:00 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: LOPEZ, ROSA AMALIA
FACILITY NUMBER: 304300450

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the licensee did not comply with the section cited above in 3 out o 3 files reviewed had expired mandated reporter training in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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copy of current mandated reporter training certificate to be sent to LPA by plan of correction date (can be emailed at patricia.rivas@dss.ca.gov
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 7 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
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licensee will update children files who require the lic 9227 and submit copy to lpa by plan of correction date.(can be emailed to patricia.rivas@dss.ca.gov
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: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 05/15/2023 11:00 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: LOPEZ, ROSA AMALIA
FACILITY NUMBER: 304300450

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review , the licensee did not comply with the section cited above in 2 out of 7 files reviewed and interview with licensee, a 15 minute check was not documented as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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licensee wil begin a 15 minute check for each infant and submit copy to lpa by plan of correction date (copy of check for two days can be sent to LPA via email at patricia.rivas@dss.ca.gov)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review , the licensee did not comply with the section cited above in 2 out of 7 files reviewed and interview with licensee, a 15 minute check was not documented as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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licensee wil begin a 15 minute check for each infant and submit copy to lpa by plan of correction date (copy of check for two days can be sent to LPA via email at patricia.rivas@dss.ca.gov)
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: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6