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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313427
Report Date: 12/29/2022
Date Signed: 12/29/2022 11:31:10 AM


Document Has Been Signed on 12/29/2022 11:31 AM - 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:BARRACOSO, KATHRYNE & BARRACOSO, SHEMAIAHFACILITY NUMBER:
304313427
ADMINISTRATOR:BARRACOSO, KATHRYNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 395-9751
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:14CENSUS: 8DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Shemaiah Barracoso, LicenseeTIME COMPLETED:
11:50 AM
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On 12/29/2022 an annual required inspection was conducted at the facility by Licensing Program Analyst (LPA), Stella Gutierrez. LPA observed licensee, Shemaiah Barracoso and assistant, Annibelle Arizabal caring for 07 preschool and school age children. LPA did not observe any infants (Under 2 years of age) present during today's visit. Licensee was operating within the licensed capacity as specified on license. Hours of operations are Monday- Friday 7:00 AM – 5:30 PM. Entrance checklist (LIC 126) provided to Licensee 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. A review of the Facility Personnel Report Summary conducted on 12/29/2022 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

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 child's sefety first gates (stairs) and closed doors. The child care area consist of the living room and dining roo,m/family room which is accessed through the front door of the home. . The children walk through the hallway by front door to access the bathroom. Licensee stated the children's primary area is the living room. There are working carbon monoxide, smoke detector, and fire extinguisher (Fire extinguisher does not have a service tag) 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. Page 1 of 5

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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: BARRACOSO, KATHRYNE & BARRACOSO, SHEMAIAH
FACILITY NUMBER: 304313427
VISIT DATE: 12/29/2022
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There is a fireplace and/or an open-faced heater in the living room screened by a wood mounted cover and inaccessible to children in care. The home has age appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service). Licensee stated they do use an outdoor play area. There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible. There is in underground pool in the back yard that was gated, locked and observed to be within substantial compliance in accordance to title 22 regulations. Licensee stated that the pool is never open during day-care operation.

The licensee does have a current roster of children in care. 04 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) and found to be in compliance.) The licensee and assistant’s Pediatric CPR/First Aid certification expired 01/10/2022.

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. LPA observed immunization's for both licensee and assistant today.

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 stated that she currently does not offer IMS -Incidental 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

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

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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: BARRACOSO, KATHRYNE & BARRACOSO, SHEMAIAH
FACILITY NUMBER: 304313427
VISIT DATE: 12/29/2022
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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, immunizations, 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.


LPA discussed the safe sleep regulations with licensee, Shemaiah Barracoso 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.

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

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

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

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC809 (FAS) - (06/04)
Page: 3 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: BARRACOSO, KATHRYNE & BARRACOSO, SHEMAIAH
FACILITY NUMBER: 304313427
VISIT DATE: 12/29/2022
NARRATIVE
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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


Safe sleep consultation provided during today's inspection. Safe sleep 15 minute log for infant present reviewed during today's consultation. LPA, Gutierrez asked Licensee if she had any questions or concerns about Infant Safe Sleep regulations 102425. A copy of thIs regulation was provided to Licensee. Licensee had no questions or concerns at this time.

Based on LPAs observations and records reviewed the following violations were observed are being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 3, Section 102417 (g) (1), 102416 (c), 102418 (g)(1) and Health and Safety code 1596.8662 (b)(1) , are being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with the licensee, Shemaiah Barracoso. 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.

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

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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: BARRACOSO, KATHRYNE & BARRACOSO, SHEMAIAH
FACILITY NUMBER: 304313427
VISIT DATE: 12/29/2022
NARRATIVE
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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: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 12/29/2022 11:31 AM - 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: BARRACOSO, KATHRYNE & BARRACOSO, SHEMAIAH
FACILITY NUMBER: 304313427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022

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: (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
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Based on observation, the licensee did not comply with the section cited above in 01 out of 01 objects which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2023
Plan of Correction
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Licensee understands that the fire extinguisher needs to be serviced annually and service tag attached to extinguisher or a newly purchased fire extinguisher annually with sales receipt attached to extinguisher. Licensee agrees to provide one of these two required specified by the date mentioned on 01/06/2023 to LPA email @ stella.gutierrez@dss.ca.gov
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(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
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Based on record review, the licensee did not comply with the section cited above in 01 out of 02 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2023
Plan of Correction
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Licensee agrees to have Annibelle Arizabal complete the mandated reporter training by visiting site mandatedreporterca.com and completing the general and child care provider training's. Licensee will submit this certificate of completion to LPA via email to stella.gutierrez@dss.ca.gov by the specified date of 01/06/2022
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: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 12/29/2022 11:31 AM - 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: BARRACOSO, KATHRYNE & BARRACOSO, SHEMAIAH
FACILITY NUMBER: 304313427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
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.

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 01 out of 01 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2023
Plan of Correction
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Licensee, Shemaiah Barracoso CPR /First Aid (pediatric and adult) not current and expired on 01/10/2022. Licensee understands that this could be a potential risk to the children in care and will complete this training and submit certificate of completion to LPA to stella.gutierrez@dss.ca.gov by the specified date mentioned of 01/13/2023.
Type B
Section Cited
CCR
102418(g)(1)
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.

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 03 out of 04 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2023
Plan of Correction
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Licensee understands that in addition to having immunization records in each child's file that a PM 286 (Non school age) must also be placed in the file and completely filed out using the immunization record. This form does not require only blue paper. Licensee will have this form complete for Child #1, #2 and #4 by the specifies date of 01/06/2022 and forward this correction to LPAs email stella.gutierrez@dss.ca.gov by the specified date of 01/06/2023.
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: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
LIC809 (FAS) - (06/04)
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