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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310159
Report Date: 10/23/2020
Date Signed: 10/29/2020 01:09:33 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:PEREIRA, BELINDAFACILITY NUMBER:
304310159
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
10/23/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Licensee Ms.Pereira BelindaTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Ketki Desai conducted an unannounced Virtual Case Management License initiated inspection (What’s App Video call) for a change in capacity at the existing Family Child Care home. Currently the family is operating under the unique Waiver as a Large Family Child Care home. LPA met with Licensee Ms. Pereira Belinda, via video call and licensee gave a tour of the home. Per Licensee, family members residing in the home are three more adults.

A review of the Facility Personnel Report Summary dated (10/23/20) indicates all adults and assistants, residing in the home who require caregiver background check clearances exemptions.

Licensee is requesting a Large family childcare home license. She has been a provider since May 2005. Per Licensee, operation hours will be Monday to Friday, 6.30 AM to 5.15 PM, care and supervision shall be provided to children ages Infant to school age. (0-15 years of age). Licensee has two of the family members as an assistant, they have completed all the requirements.

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a two story Condo home that consists of 3 bedrooms, 1 and half restrooms, living room, kitchen, dining area, and a back yard. Garage is detached. There is a stairway in the home which is made inaccessible to children by installing a child safety gate.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. The home has a central Air /Heating system, the A/C unit is installed in the area inaccessible to children.. There is a fireplace in the living room screened by a glass cover and inaccessible to children in care.

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
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: PEREIRA, BELINDA
FACILITY NUMBER: 304310159
VISIT DATE: 10/23/2020
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Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. Licensee states (that there are no poisons on the premises). Licensee was advised that any poisons must be locked with a key or combination lock. Laundry room is inaccessible to children located on the second level of the home.

Based on the Facility Sketch submitted, areas off limits to children and parents are: Entire second level of the home, (3 bedrooms and one bathroom), are inaccessible. Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Areas Designated for Day care activities: Children shall enter the home through the main door of the home, into a small hallway, there is sanitizer dispenser at the main entrance door , upon entering temperatures are checked, on the left hand side is the kitchen, which is open and all the cabinets have child safety locks installed, making it safe. Living and Dining area are the main areas designated for Child Care activities. Living area has a clean carpet where children engage in napping and other additional activities. It has age appropriate toys and educational material for children. Dining area is also utilized during food related activities. Upon entrance on the right side is the designated Day care bathroom, it was observed to be safe and free of hazardous items. Sink cabinet has a child safety lock on it.

There is a changing station for the infants to be changed and cleaned. All the items shall be provided by the parents.

Designated day care area is open and spacious, younger infants shall use a crib for napping while older infants and preschoolers shall nap in the day care area, in the carpeted areas with blankets over and under them which are taken home for weekly washes

LPA have provided the new PIN (20-24-CCP) Safe sleep regulation released on September 15th 2020, also discussed that the younger infants need to be checked every 15 minutes and document their condition to check for any distress, including their breathing pattern, skin color, body temperature and restlessness.

Licensee provides daily breakfast/ Lunch and snacks to enrolled children. Water is provided by Licensee; it is filled in their individual sports water bottles are kept on the table for easy access.

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
LIC809 (FAS) - (06/04)
Page: 2 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: PEREIRA, BELINDA
FACILITY NUMBER: 304310159
VISIT DATE: 10/23/2020
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OUTDOOR PLAY AREA: Licensee has assigned the back yard for outdoor activities, it is completely fenced and has mats covering the concrete flooring, several age appropriate toys and climbing structures are placed. There is wooden emergency door with a locked latched along with fenced area. Patio was observed to be safe for outdoor activities.

There is one pet (Dog) in the home.

Per licensee, there are no firearms, weapons or bodies of water on the premises.

The value on the 2A10BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable.

Licensee have completed the required Health and Safety with Lead and Nutrition training and Pediatric First Aid and CPR which expires on 1/2021, is completed by all the assistants in the home. There are first aid supplies available.

The following was discussed with the applicant:
·Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately.
Civil Penalties will be assessed if not in compliance.

·In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification and a valid criminal record clearance associated to the facility license.
·Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.

·The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
Applicant was also made aware of the Child Advocacy program so she could receive the updated Quarterly reports and other information in a timely manner. ChildCareAdvocatesProgram@dss.ca.gov (Page-3)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
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: PEREIRA, BELINDA
FACILITY NUMBER: 304310159
VISIT DATE: 10/23/2020
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Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
Fire and safety drills must be performed every six months and documented for review by the Department.
Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

UPDATE: H&S 1597.622: 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.
The licensee has submitted proof of immunization's.

UPDATE: Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com

Infant Care: Applicant states that she will care for infants. LPA advised the Applicant to sleep infants where they can always be directly supervised and advised against sleeping infants in a separate room. Licensee states the following as a supervision plan for infants: The infants will sleep in the designated living area where she will be providing supervision and they shall not be left unattended. LPA shared a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics, via email. Online copy can be downloaded at: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf



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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
LIC809 (FAS) - (06/04)
Page: 4 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: PEREIRA, BELINDA
FACILITY NUMBER: 304310159
VISIT DATE: 10/23/2020
NARRATIVE
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Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with applicant 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

Incidental Medical Services (IMS): This facility plans to provide Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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


OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
 Handouts provided for Never Shake a Baby, Sudden Infant Death Syndrome (SIDS) and Safe Sleeping practices
 Capacity Handout for a Small Family Child Care Home and Large Family Child Care Home was provided.

Orange County Fire authority have granted the fire clearance (10/22/20) with specific instructions: Garage and second level are not approved for Childcare.

The facility was in compliance for a (Large Family Child Care Home) with Title 22 Regulations at the time of inspection. A license will be issued after final review, in the event additional requirements are needed, the applicant will be notified. (page-5)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
LIC809 (FAS) - (06/04)
Page: 5 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: PEREIRA, BELINDA
FACILITY NUMBER: 304310159
VISIT DATE: 10/23/2020
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On today’s inspection each child was observed to have a safe, healthful and comfortable accommodation furnishing and equipment’s.

The report was read and emailed to the Licensee, (Ms. Pereira Belinda) and the read receipt shall serve in lieu of the signature. Appeal rights were also emailed to the Licensee.

Exit interview conducted via face time with the Licensee, Ms. Pereira Belinda, who agreed with the same.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
LIC809 (FAS) - (06/04)
Page: 6 of 6