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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310078
Report Date: 02/04/2022
Date Signed: 02/04/2022 04:48:32 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:ROJAS, MARILUFACILITY NUMBER:
304310078
ADMINISTRATOR:ROJAS, MARILUFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 306-4470
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:14CENSUS: 10DATE:
02/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Marilu Rojas - LicenseeTIME COMPLETED:
05:15 PM
NARRATIVE
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An unannounced case management report was initiated on today’s date by Licensing Program Analyst (LPA) Odom, during an Investigation, records reviewed of the staff and interviews. LPA discovered that Staff #3 (S3) was missing immunization.

During today's inspection there were 4 preschool age and 6 school age children present in childcare room playing. Licensee and 1 assistant were present in the childcare.

A review of staff records on this date (2/4/22) indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

At 2:30pm, during file reviews LPA observed S3’s file was missing their immunization records. Licensee stated, S3 provided a copy of their immunization records but licensee misplaced them. Licensee asked S3 if they had a copy on hand, but S3 did not have a copy. S3 told Licensee they will make an appointment with the doctor to obtain copies of their immunization records. Based on the interviews conducted with Licensee, S3’s file does not have a copy of immunization records on today’s visit.

Licensee will be cited under the California Code of Regulations, Title 22, Division 6, Chapter 3.6, Section 1597.622(a)(1) 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 immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. See attached LIC 809D.

Exit interview was conducted with Licensee Marilu Rojas in Spanish. 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. 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

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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: ROJAS, MARILU
FACILITY NUMBER: 304310078
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/04/2022
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 immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August... This requirement was not met as evidenced by:
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Based on records review and licensee interview, staff #3 did not have proof of immunization against influenza, pertussis and measles on file. This poses a potential health and safety risk to children in care.
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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: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
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