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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312178
Report Date: 03/08/2022
Date Signed: 03/08/2022 02:57:05 PM


Document Has Been Signed on 03/08/2022 02:57 PM - It Cannot Be Edited

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:SILVA, HEMAMALIFACILITY NUMBER:
304312178
ADMINISTRATOR:SILVA, HEMAMALIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 400-2268
CITY:FOOTHILL RANCHSTATE: CAZIP CODE:
92610
CAPACITY:14CENSUS: 10DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Hemamali Silva TIME COMPLETED:
03:20 PM
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On 03/08/2022 an annual required inspection was conducted at the facility by Licensing Program Analyst (LPA), Stella Gutierrez. LPA observed licensee and assistant Cozette Molocznik caring for 10 of children; which included 4 infants and 6 preschool age, Licensee was operating within the licensed capacity as specified on license. Licensee was provided ad entrance checklist (LIC 126) upon arrival.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.



During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of safety-first gates. The child care area the family room which is accessed through the living room. The children walk through the living room to access the bathroom. Licensee stated the children's primary area is the family room. There are working carbon monoxide, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are not firearms and/or other dangerous weapons in the facility and none were observed during today's inspections.

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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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: SILVA, HEMAMALI
FACILITY NUMBER: 304312178
VISIT DATE: 03/08/2022
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There is a fireplace is the family room is screened by a mounted glass cover, safety first security gate and inaccessible to children in care. The home has age appropriate toys for the ages served. During today’s inspection. LPA verified there is a working telephone service (cellular service). Licensee stated they do not use an outdoor play area. There are no bodies of water on the premises.

The licensee does have a current roster of children in care Children’s records for all children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. 4 infant records reviewed during today’s inspection in accordance to Infant Safe Sleep regulation 102425 found not to be within compliance. 15-minute individual sleep log for 2 infants not observed. Licensee stated that she was not aware of this requirement but it's her usual practice to log baby activities for Infant #1 and #2 as it was requested by parents as well. The licensee and assistant’s Pediatric CPR/First Aid certification expireS 07/2023.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, 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. Proof of immunization against pertussis, measles for licensee and assistant were reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years.

**The LICENSEE does not provide IMS.

** 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

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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
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: SILVA, HEMAMALI
FACILITY NUMBER: 304312178
VISIT DATE: 03/08/2022
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The licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization's, Pediatric CPR/First Aid, and mandated reporter training.

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.

A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

15-minute check log discussed with licensee during today’s safe sleep consultation. LPA observed 5 pack n plays at the facility today and advised the Licensee to refer to the manufactures Manuel for safe sleep and use for the children in care. A copy of regulation 102425 Infant Safe sleep provided to Licensee during consultation.

English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 15
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: SILVA, HEMAMALI
FACILITY NUMBER: 304312178
VISIT DATE: 03/08/2022
NARRATIVE
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AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

· 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.

PIN 21-29-CCP Face Covering Requirements and Guidance for Child Care Providers Regarding Coronavirus Disease 2019 (COVID 19) was provided and licensee was to continue to message the “Three W’s”: Wash your hands. Watch your physical distance. Wear a mask. This face covering guidance is for all individuals 2 years and older, except for the exceptions (child’s development, medical exemptions, etc.) that are outlined by CDPH

Based on LPAs records review the following violation was observed and is being cited in accordance with and California Code of Regulations, Title 22, Division 12, Chapter 1 , Section 102425 (j) (2) (D) , see the attached LIC 809D.


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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 15
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: SILVA, HEMAMALI
FACILITY NUMBER: 304312178
VISIT DATE: 03/08/2022
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Exit interview conducted and report was reviewed with the licensee, Hemamali Silva. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 5 of 15
Document Has Been Signed on 03/08/2022 02:57 PM - It Cannot Be Edited

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: SILVA, HEMAMALI
FACILITY NUMBER: 304312178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2022
Plan of Correction
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Licensee understands safe sleep regulation 102425 and the requirements. Licensee understands that the will submit 4 logs of all infants in care documenting child's name, date, times, position and labored breathing for 03/09/2022 through 03/11/2022 and submit proof of this requirement to LPA by the end of the business day (5:00 PM) on 03/14/2022 to LPA via email at stella.gutierrez@dss.ca.gov Licensee understands that she needs to continue to implement Infant Safe Sleep 102425 regulation and failure to do so may result in civil penalties as a repeat violation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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