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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304311418
Report Date: 05/29/2019
Date Signed: 05/29/2019 01:17:38 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:LEMUS, GLORIAFACILITY NUMBER:
304311418
ADMINISTRATOR:LEMUS, GLORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 835-3802
CITY:SANTA ANASTATE: CAZIP CODE:
92701
CAPACITY:14CENSUS: 8DATE:
05/29/2019
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Gloria Lemus TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) S. Hawkins made an unannounced visit to the facility to conduct an inspection to ensure the facility is complying with licensing regulations. Present at the start of this licensing report was licensee, assistant Alberto Sandoval and eight children in care (2 infants, 6 preschoolers). At the time of arrival children was transitioning to outdoor play. Four school age children were picked up from school and brought to the home later in the visit bringing the total number of children in care to 12.

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.

The facility was toured inside and out. The following areas were checked: facility clean and in good repair, hazards inaccessible or locked, fire extinguisher, carbon monoxide detector and smoke detector operational, stairs barricaded, fire place screened, no bodies of water. Licensee reported there were no guns or weapons in the home. Children emergency cards and Notification of Parent's Rights were present. Children's immunization records were present, but was not transferred to the California School Immunization Record, PM 286 (6/95) card as required. There was no record of fire drill/disaster drill log. Staff's pediatric CPR/First Aid cards were current (exp.9/23/19; 10/7/19) .

The facility is a two story detached home. Licensee has designated the entire downstairs for the care and supervision of children. Gate at the bottom of the staircase leading to the second story of the home is in place. Toys and educational material that appear age appropriate for children served are within the home. The fire extinguisher, smoke detector, and carbon monoxide detector are within regulation. Fireplace is screened.
The fenced side and backyard are designated for outdoor play by children in care. Outdoor toys and play equipment were age appropriate for ages served are present.

Continued on page 2
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019
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 3
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: LEMUS, GLORIA
FACILITY NUMBER: 304311418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2019
Section Cited
CCR
102417(g)(9)(A)(1)
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Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. This requirement was not met as evidenced by no record of fire drill/disaster drill log. This poses a potential Health and Safety risk to the children in care.
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Licensee will conduct fire/disaster drill, document on a log, and provide to LPA by the due date.
Type B
06/28/2019
Section Cited
CCR
102418(h)(1)
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Immunization. The family day care home shall record each pupil's immunization on the California School Immunization Record, PM 286 (6/95). This requirement was not met as evidenced by no PM286 immunizations record card for all children. Copies of children's immunization records were present. This poses a potential risk to
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Licensee will transfer immunization records to California School Immunization Record, PM 286 (6/95) and provide copies to LPA by the due date.
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the health and safety of 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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: LEMUS, GLORIA
FACILITY NUMBER: 304311418
VISIT DATE: 05/29/2019
NARRATIVE
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Continued page 2

Licensee was informed that when children in care are playing in the designated outdoor areas which are unfenced 100% visual supervision is required. There is a small dog on the premises and is separated by small gate in the family room. Dog appeared approachable and have proper license.

This facility cares for children who need incidental medical services. LPA reviewed storage of medication and equipment/supplies.
LPA reviewed requirements for children files with licensee.

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 Section 102417(g)(9)(A)(1), 102418(h)(1) were observed, discussed and cited at the time of the visit. (See LIC 809-D for specific deficiencies)
An exit Interview was conducted. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional Manager, address is above on the report.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. The NOTICE must remain posted for 30 days. FAILURE TO POST ANY OF THE REQUIRED SITE VISIT REPORTS FOR 30 CONSECUTIVE DAYS WILL RESULT IN AN IMMEDIATE CIVIL PENALTY OF $100.

Facility was provided information about :the E-Learning Modules available at https://ccld.childcarevideos.org ;


* https://www.mandatedreporterca.com/training/child-care-providers
The facility representative was informed that they can refer to our Department website at www.ccld.ca.gov for obtaining the quarterly updates.


This report ends here.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019
LIC809 (FAS) - (06/04)
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