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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304311836
Report Date: 05/07/2019
Date Signed: 05/07/2019 03:20:10 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:ALDANA, MARIAFACILITY NUMBER:
304311836
ADMINISTRATOR:ALDANA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 458-7780
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:14CENSUS: 10DATE:
05/07/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee, Aldana, MariaTIME COMPLETED:
03:45 PM
NARRATIVE
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An unannounced Random/Annual visit was conducted today by Licensing Program Analyst (LPA) Nguyen. Met with licensee, Aldana, Maria who guided analyst on a tour of the facility. Present at the time of the inspection was the licensee, licensee’s assistant Quinteros Alba and 10 day care children, 5 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 a two story home with 4 bedrooms, 2 bathrooms, front yard, backyard, and garage. Licensee has designated the following areas of the home for the care and supervision of children: day care room #1 for napping children, the bathroom downstairs, dining room, living room and the patio. OFF LIMIT areas include: all of upstairs, master bedroom downstairs, kitchen and garage. Gate at the bottom of the staircase makes the stairs inaccessible to children. Licensee acknowledges that children are never to enter an off-limit area of the home. 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. The licensee has a current roster of children in care. The facility has conducted an emergency drill within the past six months.

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. 05/13/2019) are current for the licensee. There was no proof of immunization or immunity (pertussis, measles, and influenza) on file for licensee and licensee’s assistant. Licensee and licensee's assistant primary language is not English, therefore, exempt from taking the mandated reporter training at this time. (Continued on Page 2)
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Cindy NguyenTELEPHONE: (714) 703-2834
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2019
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 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: ALDANA, MARIA
FACILITY NUMBER: 304311836
VISIT DATE: 05/07/2019
NARRATIVE
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Page 2

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. During today's inspection ten of the ten children's files reviewed did not documentation of children’s immunization on the California School Immunization Card (CDPH 286). Two of the ten children's files reviewed did not have a signed copy of the parents' rights.

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

A Child Care Provider’s Guide to Safe Sleep packet, Safety Seat, Never Ever Shake a Baby information, and Safe Sleep Regulation and Effects of Lead Exposure were discussed and provided to the licensee. 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 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 records, mandated child abuse and injury/ death reporting, and criminal records clearances/exemption transfer requests.

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

(Continued on Page 3)

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Cindy NguyenTELEPHONE: (714) 703-2834
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2019
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: ALDANA, MARIA
FACILITY NUMBER: 304311836
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2019
Section Cited
HSC
1597.622(a)(1)
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1597.622(a)(1) Employee and Volunteer Immunization (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...
This requirement is not met as evidenced by:
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Licensee stated she will provide all the required immunization record for her & her assistant Quinteros Alba to LPA by 5/28/19 by email Cindy.Nguyen@dss.ca.gov or mail to the office.
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Based on interview and record reviews, the licensee failed to ensure to maintain and obtain her & her assistant immunization record. This poses a potential Health and Safety risk to the children in care.
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Type B
05/28/2019
Section Cited
CCR
102418(g)
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102418(g) Immunizations (g)The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
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Licensee will submit proof to LPA by 5/28/19 by email Cindy.Nguyen@dss.ca.gov or mail to the office.
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Based on record reviews 8 out of 10 children have no immunization records and blue immunization cards. This poses a potential Health and Safety risk to the 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: Cindy NguyenTELEPHONE: (714) 703-2834
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2019
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: ALDANA, MARIA
FACILITY NUMBER: 304311836
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2019
Section Cited
CCR
102419(d)(1)
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The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A... This requirement was not met as evidenced by:
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The licensee stated she will have the parents sign the LIC 995A parents rights and retain the bottom portion. A copy will be sent to the licensing office by the due date of 05/28/2019.
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There was no bottom portion of the parents' rights on file for four of the eleven children's files reviewed. This poses a potential 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: Cindy NguyenTELEPHONE: (714) 703-2834
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2019
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: ALDANA, MARIA
FACILITY NUMBER: 304311836
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2019
Section Cited
CCR
102416.5(d)(1)
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102416.5 Staffing Ratio and Capacity (d) For a Large Family Child Care Home, the maximum number of children for whom care.....(1)Twelve children, no more than four of whom may be infants. This requirement is not met as evidenced by:
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The licensee will send LPA an email stated which child will be drop from the facility. The licensee stated she will not take any children if the ratio is over the maximum number at any one time. LPA Nguyen email: Cindy.Nguyen@dss.ca.gov
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Licensee was caring for ten day care children, five of which were under the age of two years. Based on observation, record reviews, and interview, the licensee failed to ensure to keep the maximum number of four infant in care at one time. This poses an immediate Health and Safety risk to the 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: Cindy NguyenTELEPHONE: (714) 703-2834
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2019
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: ALDANA, MARIA
FACILITY NUMBER: 304311836
VISIT DATE: 05/07/2019
NARRATIVE
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Page 3

Based on LPA observations and record reviews the following violations were observed and being cited in accordance with California Code of Regulations, Title 22; Division 12 code 102416.5(d)(1), 102418(g), 102419(d)(1) and Health and Safety code 1597.662 (a)(1). Please refer to attached 809Ds for documentation of deficiencies.

This report cites Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.



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 HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Cindy NguyenTELEPHONE: (714) 703-2834
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2019
LIC809 (FAS) - (06/04)
Page: 6 of 6