304312394-2-1-2021-06-CC-CODM-BXTSUA-20210201131049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304312394
Report Date: 02/01/2021
Date Signed: 02/01/2021 01:10:59 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:	HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTO		FACILITY NUMBER:	304312394
ADMINISTRATOR:	AREVALO ESPERANZA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 415-9125
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY:	14	CENSUS: 5	DATE:	02/01/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Licensee - Ascension Arevalo		TIME COMPLETED:	01:30 PM

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A case management inspection was conducted today by Licensing Program Analyst (LPA), Carmen Odom and Leonor Barajas who met with the Licensee, Ascencion Arevalo-Hernandez. Present was the Licensee, Spouse, and 2 assistants. Census was taken and there was a total of 5 children, 3 preschool age in the back-childcare room and 2 school age children in the dining room distance learning. A review of criminal record clearances indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

According to a self-report incident on 1/27/21 by the facility, a 3-year-old child eloped the childcare and assistant found the child with the neighbor. It was discovered at 9:40 am while 4 children were in the childcare dining room getting ready to eat snack. Assistant stepped out to the garage through the back-childcare room to grab snacks. About a minute later child eloped by himself through the hallway into the childcare and opened the door with a safety knob, down the driveway, and climbed up to unhook the lock and pulled the white metal driveway gate open. Assistant returned from the garage did not see child and began to look for child. It was disclosed child was missing for approximately 5-10 minutes. Assistant ran outside and found child with a neighbor. Based on interviews child walked approximately 145 adult walking steps by himself looking for Licensee but was found by a neighbor who was walking the child back. Licensee was not home when the incident occurred, and spouse was in the backyard cutting the grass. LPA took pictures of the childcare door and gate. Today LPAs discussed security measures to upgrade childcare door and gate security a the childcare facility. Licensee will place an alarm at the childcare door. Regarding the reported incident, the staff failed to visually observe the child in care. An immediate civil penalty of 500.00 was assessed today.

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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021

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: HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTO	FACILITY NUMBER: 304312394
	VISIT DATE: 02/01/2021

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In the areas that were evaluated, the facility was not in compliance of the California Code of Regulations, Title 22, Division 12. The following citation under Operation of a Family Childcare Home section 102417(a) was issued today on the attached LIC 809D.

The Notice of Site Visit was posted. Facility representative 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. The interim director was provided a copy of their appeal right (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days.

Upon receiving Type A violation, the Licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. The director is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file.

Exit interview was conducted.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021

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: HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTO	FACILITY NUMBER: 304312394
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/01/2021 Section Cited	1 2 3 4 5 6 7	102417(a) Operation of a Family Childcare Home (a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute... This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interviews, staff#1 failed to visually observe the 3-year-old child in care there was absence of supervision for about 5-10 mintues. Child was found outside the childcare facility by a neighbor. This poses an immediate Health and Safety risk to the children in care.	8 9 10 11 12 13 14	Civil Penalties has been assessed for $500.
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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 Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021

LIC809 (FAS) - (06/04)

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