304312537-5-10-2023-06-CC-PRIS-CRQ2YQ-20230510174906

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304312537
Report Date: 05/10/2023
Date Signed: 05/10/2023 05:57:22 PM

Document Has Been Signed on 05/10/2023 05:57 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:	CHANDRASEKARAM, MARY		FACILITY NUMBER:	304312537
ADMINISTRATOR:	CHANDRASEKARAM		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 738-4317
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	14	CENSUS: 7	DATE:	05/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Maria Huerta, Asst		TIME COMPLETED:	06:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAS) P Rivas and G Lucero conducted an unannounced annual inspection and met with Asst, Maria Huerta and together conducted a physical plant tour of home. Upon arrival LPAs viewed 7 children napping and one other assistant (Staff #3 S3) caring for children. Licensee, Mary Chandrasekaram arrived at 2:30pm. The hours of operation are M-F 7:00am to 6:00pm. A review of the Facility Personnel Report Summary via Guardian was conducted on 05/10/2023 and found that staff #3 , (Rocio Villalon) did not have fingerprint clearances on file. Licensee stated she was "trying her out". Licensee further stated that Ms. Villalon had worked full time M-F for the last two weeks since licensee needed assistance. Ms. Villalon had stated she began working part time since 02/22/23. Civil penalties will be issued and A Citation under 102370(d)(1) is being issued. During today’s inspection, LPA toured the inside and outside areas identified in the facility sketch as accessible to childcare children. The following was observed and reviewed during this inspection. The living room, kitchen and two bedrooms, downstairs bathroom and outside yard area. LPA noted no gate was in place upon entrance therefore LPAs and Assistant Huerta toured upstairs. A citation will be issued under 102417(g)(3)Operation of a Family Child Care Home There are no bodies of water on the premises. The Licensee was reminded that full supervision is required at all times to ensure children do not have access to the off-limit areas. cont on Page 2

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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: CHANDRASEKARAM, MARY	FACILITY NUMBER: 304312537
	VISIT DATE: 05/10/2023

NARRATIVE

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There are working carbon monoxide, smoke detector were operational. The Fire Extinguisher was purchased 10/21 which does not meet State Fire Marhsall's Requirement to have extinguishers serviced annually. A Citation will be issued under102417(g)(1) Operation of a Family Child care home. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children.
There are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. The facility has age appropriate toys for the ages served. LPA verified there is a land line.The licensee does have a current roster of children in care.
The licensee's Pediatric CPR/First Aid certification expires on 09/2024. 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. Three staff files reviewed had immunizations as required.
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. Three out of three files reviewed did not have current mandated reporter training. Citation will be issued under;
H& S1596.8662(b)(1)

Incidental Medical Services (IMS) policy was discussed. States she does not have anyone on medication. For IMS information see PIN 22-02-CCP: Best Practices Related to the Provision of Incidental Medical Services in Child Care Centers and Family Child Care Homes. 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

The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone 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, immunizations, Pediatric CPR/First Aid, and mandated reporter training.CCLD website www.cdss.ca.gov

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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: CHANDRASEKARAM, MARY	FACILITY NUMBER: 304312537
	VISIT DATE: 05/10/2023

NARRATIVE

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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 Child Care Providers Guide to Safe Sleep” was discussed to the licensee.

The following electronic links were also provided: NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

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

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage 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.

LPA reviewed with licensees 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 if 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.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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: CHANDRASEKARAM, MARY	FACILITY NUMBER: 304312537
	VISIT DATE: 05/10/2023

NARRATIVE

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In the areas that were evaluated, The following deficiencies were observed under the California Code of Regulations Title 22 and H & S Codes.
A Violation;
102370(d)(1) Criminal Record Cleanraces-Staff #3 Rocio Villalon did not have criminal record clearances.
B Violations
102417(g)(3)Operation of a Family Child Care Home; Stairs were not barricaded/gated
102417(g)(1)Operation of a Family Child Care Home; fire extinguisher was more than 1 year old
H& S1596.8662(b)(1) Mandated Reporter Training - three of three files did not have a current mandated reporter training on file
H&S 1597.622(c) 2 staff did not have immunizatio on file.

102425(c) Infant Safe Sleep- An individual Safe Sleep Plan (lic 9227) was not in C1's file

102425(j)(2) Infant Safe Sleep- a 15 minute sleep check log was not completed or in file for C1.

LPA Rivas informed Licensee CHANDRASEKARAM, MARY that this report dated 05/10/2023 document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Rivas informed the new proposed licensee CHANDRASEKARAM, MARY to provide a copy of this licensing report dated 05/10/23 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification

Exit interview was conducted with licensee CHANDRASEKARAM, MARY. Notice of Site Visit was posted during the visit. Director 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. Director was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/10/2023 05:57 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: CHANDRASEKARAM, MARY	FACILITY NUMBER: 304312537
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(1)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation LPA noted that The fire extngisher was purchased 10/21 which is more than 1 year old licensee did not comply with the section cited above in 1 out of 1 exntinguisher in the home. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2023
	Plan of Correction
1 2 3 4	licensee will purchase new fire extingisher and send copy of receipt to LPA Rivas by plan of correction date . can email it to patricia.rivas@dss.ca.gove

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 Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/10/2023 05:57 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: CHANDRASEKARAM, MARY	FACILITY NUMBER: 304312537
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(3)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation (picture taken), the licensee did not comply with the section cited above The gate was not in place by staircase, upon LPAs entrance into facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2023
	Plan of Correction
1 2 3 4	staff placed gate during visit; licensee states she will place gate back in place before she leaves facility. Statement to be sent to LPA by plan of correction date

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 Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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: CHANDRASEKARAM, MARY	FACILITY NUMBER: 304312537
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102370(d)(1)

102370 Criminal Record Clearance All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, licensee stated Staff Villalon did not have criminal record clearance because she was just trying her out. Ms. Villalon worked full time for two weeks Monday to Friday 8am to 5pm since but worked part time from 02/22/23. The licensee did not comply with the section cited above in 1 out of 1 criminal record clearances reviewed. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/11/2023
	Plan of Correction
1 2 3 4	LIcensee will not have any person work, reside or volunteer until a criminal record clearance is obtained. Licensee will have staff Villalon obtain criminal record clearances and provide copies to to plan of correction date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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: CHANDRASEKARAM, MARY	FACILITY NUMBER: 304312537
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Hs 1596.8662(b)(1) Mandated Reporter Training (1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 files reviewed. No staff had current mandated reporter traiining in file. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2023
	Plan of Correction
1 2 3 4	licensee and staff will take mandated reporter training and provide copy of certificates to LPA by plan of correction date . Certificates can be emailed to patricia.rivas@dss.ca.gov

Type B

Section Cited

HSC

1597.622(c)

The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 3 files, staff did not have proof of immunizations in file. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	licensee will have staff provide copies of immunizations for pertussis, measles and influenza tuberculosis and provide copy to lpa Rivas by plan of correction date

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 Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/10/2023 05:57 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: CHANDRASEKARAM, MARY	FACILITY NUMBER: 304312537
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 7 files reviewed. Child #1(C1) was admitted in March 2022 when child was still under 2, review of records did not have lic 9227 Individual Infant Sleep Plan in file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	licensee will review regulations under infant safe sleep and provide lpa statement that she understands regulations

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

Page: 10 of 10

Document Has Been Signed on 05/10/2023 05:57 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: CHANDRASEKARAM, MARY	FACILITY NUMBER: 304312537
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)

Infant Safe Sleep The provider shall supervise infants while they are sleeping and adhere to the following requirements: check and document 15 minute check for infants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 1 files. hich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	licensee will create a log and train staff, review videos. copy of log and training.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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