304300937-6-11-2019-06-CC-CNGN-BD2Q3N-20190611114902

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304300937
Report Date: 06/11/2019
Date Signed: 06/11/2019 11:49:10 AM

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:	GONZALEZ, ADRIANA MARIA		FACILITY NUMBER:	304300937
ADMINISTRATOR:	GONZALEZ, ADRIANA MARIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 581-4651
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	14	CENSUS: 10	DATE:	06/11/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Licensee, Gonzalez, Adriana Maria		TIME COMPLETED:	12:30 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 unannounced Random/Annual visit was conducted today by Licensing Program Analyst (LPA) Nguyen. Met with licensee, Gonzalez, Adriana who guided analyst on a tour of the facility. Present at the time of the inspection was the licensee, licensee’s assistant Mozeika, Sabrina and 10 day care children, 3 of which were under the age of two years. A review of adults living or working in the home on this date indicated individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The facility is two story with 4 bedrooms and 2 bathrooms. Licensee designated the following areas of the home for the care and supervision of children: living room, dining room, kitchen, the two rooms downstairs (one is set up as a playroom, second room is set up as an infant sleeping area), the bathroom downstairs and the enclosed backyard. OFF LIMIT areas include: all of upstairs and the attached garage. LPA observed a gate at the bottom of the stairs. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medication, and hazardous items that could pose a danger to children. Fire drill log, children's records and rosters were reviewed on today's inspection. Children's records for the children present during LPA's inspection were reviewed for: Immunization and updates records, and a signed copy of the Family Child Care Home Notification of Parents’ Rights. Licensee stated there are no firearms on the premises. LPA advised anytime when firearms are present, they must be locked and stored separately from the ammunition. No swimming pool, spa or other bodies of water observed on the premises. There are age appropriate toys and equipment on the premises for the ages served. The required fire extinguisher (2A10BC), carbon monoxide, and smoke detectors are in operable condition. LPA observed CPR & First Aid (exp. 5/11/21) are current for the licensee. Current immunization information for pertussis, measles, influenza, and mandated reporter training were verified by LPA for licensee and licensee’s assistant. (Continued on Page 2)

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Cindy Nguyen	TELEPHONE: (714) 703-2834
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019

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: GONZALEZ, ADRIANA MARIA	FACILITY NUMBER: 304300937
	VISIT DATE: 06/11/2019

NARRATIVE

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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

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 record, mandated child abuse and injury/ death reporting, and criminal records clearances/exemption transfer requests. Providers guide to Safe Sleep, Never Shake a Baby, Ratio and Capacity, 25 E-learning Modules, Lead exposure information, and California Child Passenger Safety Law. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf. The below links offer more information on safe sleep to our providers https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx. https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

The licensee was also informed to visit the www.ccld.ca.gov website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov

In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

(Continued on Page 3)

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Cindy Nguyen	TELEPHONE: (714) 703-2834
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019

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: GONZALEZ, ADRIANA MARIA	FACILITY NUMBER: 304300937
	VISIT DATE: 06/11/2019

NARRATIVE

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Exit interview was conducted. Report reviewed and discussed with the licensee. “The licensee was provided a copy of their appeal rights (LIC 9058 1/16) 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 day care hours or $100 civil penalty will be assessed. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Cindy Nguyen	TELEPHONE: (714) 703-2834
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019

LIC809 (FAS) - (06/04)

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