304312818-7-11-2019-06-CC-JMHN-BDYKDN-20190711074902

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304312818
Report Date: 07/10/2019
Date Signed: 07/11/2019 07:49:12 AM

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:	ALVAREZ, DENISSE		FACILITY NUMBER:	304312818
ADMINISTRATOR:	ALVAREZ, DENISSE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(951) 229-4130
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	14	CENSUS: 9	DATE:	07/10/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Denisse Alvarez		TIME COMPLETED:	11:15 AM

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 Analyst (LPA), Han conducted an unannounced annual/random inspection of the facility on today's date. LPA Han toured the facility with the licensee, Denisse Alvarez and a census taken. Observed was licensee, an assistant, seven children, two who were under the age of two. At about 9:00AM, a licensee’s spouse arrived at the facility and staff#3 left the facility. At 9:30AM, there were total nine children, two who were under the age of two. A review of staff criminal clearance 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 or exemptions. The LPA toured the facility inside and outside. Medication storage, 1^st aid kit, and cleaning supplies storage were inspected. Facility met all posting requirement. The facility clean and in good repair, hazards inaccessible or locked, stairs barricaded, fire places screened. There are age appropriate toys and equipment on the premises. The required fire extinguisher (2A10BC), carbon monoxide, and smoke detectors are in operable condition. LPA Han observed the kitchen drawer latch needs to be replaced. Nail polish was accessible in the kitchen drawer. Per Licensee there are no weapons in the facility at this time. Licensee provides breakfast, lunch, and snacks. Licensee offers 2% milks for all age children. Licensee was informed to offer only 1% or less to over 2 years old children. Licensee stated off limit areas include: entire upstairs and garage. Facility files were reviewed, including liability insurance for family child care home and facility roster. Fire and disaster drill log was not available to review. Licensee and three staff records were reviewed, including TB test and Criminal Record Statement. Immunization records (Measles, Pertussis, and Influenza), current CPR and First Aid, and Mandated Reporter Training Certificates were not available to review at the time of the facility inspection.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019

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: ALVAREZ, DENISSE	FACILITY NUMBER: 304312818
	VISIT DATE: 07/10/2019

NARRATIVE

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https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

No smoking on premises, infant walkers, bouncers, Johnny jumpers, exersaucer or any other similar items that fall into that category are allowed in the facility.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (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.
Any proposed changes to the physical plant, including telephone number, shall be immediately reported to the Department.
The 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 $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019

LIC809 (FAS) - (06/04)

Page: 5 of 8

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: ALVAREZ, DENISSE	FACILITY NUMBER: 304312818
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Facility Administration - Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
	Deficient Practice Statement
1 2 3 4	Based on observation, licensee faile to ensure to maintain current pediatric CPR/1st Aid. This poses a potential Safety risk to the children in care.
	POC Due Date: 08/10/2019
	Plan of Correction
1 2 3 4	Licensee will submit proof of current pediatric CPR/1st Aid certificate by due date by email. JUNGMI.HAN@DSS.CA.GOV

Type B

Section Cited

CCR

102417(g)(7)

Records - Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, licensee failed to ensure to maintain child#1's required documents such as emergency information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Notification of parents' Rights (LIC 995A), Immunization Reocrd (PM 286), and Affidavit Regarding Liability insurance (LIC 282).
	POC Due Date: 08/10/2019
	Plan of Correction
1 2 3 4	Licensee will submit required documents for child#1 by due date by email.

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: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019

LIC809 (FAS) - (06/04)

Page: 2 of 8

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: ALVAREZ, DENISSE	FACILITY NUMBER: 304312818
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(4)

Physical Plant

102417 (g)(4) Operation of a Family Child Care Home (g)The home shall be free from... might endanger a child. Safety precautions shall include but not be limited to (4) ...detergents, cleaning compounds...which could pose a danger..they are inaccessible to children. This requirement is not meet as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, licensee failed to ensure to maintain kitchen drawer latch in place. LPA observed nail polish in the kitchn drawer.This poses a potential Health and Safety risk to the children in care.
	POC Due Date: 08/10/2019
	Plan of Correction
1 2 3 4	Licensee will replace kitchen drawer latch and submit proof by email by due date. JUNGMI.HAN@DSS.CA.GOV

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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019

LIC809 (FAS) - (06/04)

Page: 7 of 8

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: ALVAREZ, DENISSE	FACILITY NUMBER: 304312818
	VISIT DATE: 07/10/2019

NARRATIVE

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Eight children’s records were reviewed, including, Notification of parents’ rights, Parent notification additional children in care, Parent notification additional children in care, Identification and Emergency information, Consent for emergency medical treatment, Affidavit regarding liability insurance for family child care home, and Acknowledgement of receipt of licensing reports which it issued on 3/8/2018. Children's’ immunization records were available to review, but licensee did not update immunization record on PM 286 (blue card). Child#1 was at the facility at least last three weeks. Licensee did not have files for child#1. Child#1 is a sibling of child#2.
Licensee is not current with Pediatric CPR and First Aid and both valid until 8/2018. Licensee was reminded that licensee must present at facility and ensure that children are properly cared for and supervised at all times. Licensee must make sure that a substitute adult cares for the children when licensee is temporarily absent. The licensee was also reminded that no child shall be left alone in a parked vehicle at any time.

Licensee does not provide Incident Medical Services.
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

Based on LPAs observations, record reviews, and interviews the following violations were observed are being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 102417(g)(9)(A), 102416(c), 102418(g)(1), 102417(g)(7), 102417(g)(4) and Health and Safety 1596.8662(b)(1), 1597.622 (a)(1). Please refer to attached 809D for documentation of deficiencies.

The following was discussed with licensee: Providers guide to Safe Sleep, Never Shake a Baby, Ratio and Capacity, Quarterly updates, Advocate program contact, 25 E-learning Modules, Mandated Reporter training, Criminal record clearance, Unusual Incident Report (LIC624B), AB 2084 (Nutritious Beverages), Immunization for staff, Indoor/Outdoor activity space equipment condition, Lead exposure information, California Child Passenger Safety Law, Supervision. 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 below links offer more information on safe sleep to our providers

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019

LIC809 (FAS) - (06/04)

Page: 4 of 8

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: ALVAREZ, DENISSE	FACILITY NUMBER: 304312818
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

Records

102417(g)(9)(A) Operation of a Family Child Care Home.(A) 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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with licensee, licensee fail to ensure to conduct the fire and disaster drill. This poses a potential Safety risk to the children in care.
	POC Due Date: 08/10/2019
	Plan of Correction
1 2 3 4	Licensee will conduct the fire and disaster drill and submit its proof by email by due date. JUNGMI.HAN@DSS.CA.GOV

Type B

Section Cited

HSC

1596.8662.(b)(1)

Records

1596.8662.(b)(1)… mandated reporter…proof of completion ...January 1, 2018, is a licensed child care provider..shall complete the mandated reporter training provided...renewal mandated reporter training every two years...This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, licensee failed to ensure to have mandated reporter training certificates for staff and herself. This poses a potential Safety risk to the children in care.
	POC Due Date: 08/10/2019
	Plan of Correction
1 2 3 4	Licensee will submit 3 staff and 1 licensee's mandated reporter training certificates by email by due 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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019

LIC809 (FAS) - (06/04)

Page: 6 of 8

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: ALVAREZ, DENISSE	FACILITY NUMBER: 304312818
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)(1)

Records - 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. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.
	Deficient Practice Statement
1 2 3 4	Based on observation, licensee failed to ensure to update each child's immunization record on blue card (PM 286) This poses a potential Safety risk to the children in care.
	POC Due Date: 08/10/2019
	Plan of Correction
1 2 3 4	Licensee will submit 8 children's updated blue card by email by due date. JUNGMI.HAN@DSS.CA.GOV

Type B

Section Cited

HSC

1597.622(a)(1)

Records - Family Day Care Homes

(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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, licensee failed to ensure to maintain staff's immunization records against influenza, pertussis, and measles. This poses a potential Safety risk to the children in care.
	POC Due Date: 08/10/2019
	Plan of Correction
1 2 3 4	Licensee will submit 3 staff and licensee's immunization records (influenza, pertussis, and measles) by email by due 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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019

LIC809 (FAS) - (06/04)

Page: 3 of 8