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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313256
Report Date: 02/16/2022
Date Signed: 02/16/2022 03:19:50 PM


Document Has Been Signed on 02/16/2022 03:19 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:JAUREGUI, MARTHAFACILITY NUMBER:
304313256
ADMINISTRATOR:MARTHA JAUREGUIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 615-2590
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:14CENSUS: 0DATE:
02/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Martha Jauregui - LicenseeTIME COMPLETED:
03:35 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Carmen Odom. LPA observed licensee, caring for a total of 6 children; 1 infant, and 5 preschool age children napping in the childcare area. Licensee was operating within the licensed capacity as specified on license. Due to State of Emergency COVID-19, LPA observed staff and children wearing face mask, social distancing and following CDC and Department of Public Health Guidelines.

A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 2 adults including the licensee and 1 minor child living in the facility. Facility Day care hours are 7:00 am-5:00 pm, Monday through Friday.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of baby gates and baby locks. The childcare area consists of the living room, and bathroom located down the hallway on the left side. Licensee stated the children's primary area is the childcare room. There are working carbon monoxide, smoke detector, and fire extinguishers 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 no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. There is no fireplace in the facility. The facility has central air conditioning. The home has age appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service). Licensee stated, they use the backyard for outdoor play, LPA inspected the backyard and within compliance. There are no bodies of water on the facility.

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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2022
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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Document Has Been Signed on 02/16/2022 03:19 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: JAUREGUI, MARTHA
FACILITY NUMBER: 304313256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not document on a log the fire drill done on 01/2022. Licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2022
Plan of Correction
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Licensee stated, they will conduct a fire drill, document the drill on the fire drill log and send in a copy to the licensing office by the due date above.

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: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/16/2022 03:19 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: JAUREGUI, MARTHA
FACILITY NUMBER: 304313256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022

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: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not have a sleeping log for Child #4. Licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee stated, they will document on the sleeping log when infant is checked on every 15 minutes and provide a copy to the licensing office the due date above.
Type B
Section Cited
CCR
102425(j)(2)(A)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Labored breathing.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not have a sleeping log for Child #4 and did not document for labored breathing. Licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee stated, they will document on the sleeping log when infant is checked on every 15 minutes and on their labored breathing. Licensee will provide a copy to the licensing office the due date above.

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: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/16/2022 03:19 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: JAUREGUI, MARTHA
FACILITY NUMBER: 304313256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(B)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Signs of distress which includes but is not limited to flushed skin color, increase in body temperature and restlessness.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not have a sleeping log for Child #4 and did not document for signs of distress. Licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee stated, they will document on the sleeping log when infant is checked on every 15 minutes and for signs of disress. Licensee will provide a copy to the licensing office the due date above.
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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
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: JAUREGUI, MARTHA
FACILITY NUMBER: 304313256
VISIT DATE: 02/16/2022
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The licensee has a current roster of children in care. Children’s records for 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), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A) and found to be in compliance. Licensee stated there are no infants under 12 months enrolled in the childcare and LPA reviewed form LIC 9227 Individual Infant plan with licensee. During inspection at 12:30pm, LPA Odom observed 1 infant under 24 months, and sleeping log was missing. During inspection at 1:00pm, Licensees stated, the last fire drill was conducted on 1/2022 but it was not documented on a log.

The licensee’s Pediatric CPR/First Aid certification expired 12/2022. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee 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.

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

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. LPA provided Guardian Information and website info:
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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
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: JAUREGUI, MARTHA
FACILITY NUMBER: 304313256
VISIT DATE: 02/16/2022
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https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

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 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.

Updated face covering guidance 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.
Important COVID-19 resources and links were provided:
· COVID-19 Update Guidance Childcare Programs/Providers link:
https://files.covid19.ca.gov/pdf/guidance-childcare.pdf
· CCLD COVID-19 Licensed childcare and facilities and provider FAQs link: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/child-care-licensing/covid-19-child-care-resources/faqs-for-licensed-child-care-facilities-and-providers
Safe, free, and effective COVID-19 vaccines are now available to everyone age 16 and up. Every Californian can sign up at myturn.ca.gov or call (833) 422-4255 to get their COVID-19 vaccine appointment.
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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
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: JAUREGUI, MARTHA
FACILITY NUMBER: 304313256
VISIT DATE: 02/16/2022
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The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: Operation of Family Child Care Home 102417(g)(9)(A)1, Infant Safe Sleep 102425(j)(2), Infant Safe Sleep 102425(j)(2)(A), and Infant Safe Sleep 102425(j)(2)(B) (see LIC 809D).

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.

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.

Exit interview conducted and report was reviewed with the licensee Martha Jauregui. A notice of site visit was given and must remain posted for 30 days.

Appeal Rights were explained. The Licensee was provided a copy of 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 Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC809 (FAS) - (06/04)
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