304313603-6-12-2019-06-CC-GMAI-BD3N8N-20190612101437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313603
Report Date: 06/12/2019
Date Signed: 06/12/2019 10:14:45 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:	SALAZAR, VICTORIA		FACILITY NUMBER:	304313603
ADMINISTRATOR:	SALAZAR, VICTORIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(657) 254-6761
CITY:	IRVINE	STATE: CA	ZIP CODE:	92620
CAPACITY:	14	CENSUS: 0	DATE:	06/12/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Victoria Salazar - Applicant		TIME COMPLETED:	10:30 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 Analysts (LPAs), Gigi Mai and Dean Valencia conducted an announced Pre-Licensing inspection of the home on today's date. The LPAs toured the home with the applicant, Victoria Salazar. The applicant has requested a license for a large family child care home with operating hours of Monday through Friday 7:00 AM to 7:00 PM. A review of adults' records on today's date indicates that all adults live in the home or individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The facility is a two-story family home with 3 bedrooms, loft, 2.5 bathrooms, living room, dining room, kitchen, attached garage, front yard and fenced backyard. The home was clean, orderly, and was at a comfortable temperature. Fireplace located in the living room is barricaded. Off limits areas are: kitchen, entire upstairs and garage. Applicant has placed a baby gate at bottom of the stairs and kitchen area.
Cleaning solutions/chemicals, utensils, and sharp knives are all inaccessible. Applicant stated poisons/hazardous items are not kept on the premises. Applicant understands that cleaning solutions/chemicals must be made inaccessible to children at all times and poisonous items must be key/combo locked at all times.

There are age appropriate toys and napping equipment on the premises for the potential ages served. There are no bodies of water on the premises. The applicant stated that there are no firearms on the premises. LPAs advised anytime when firearms are present, they must be locked and stored separately from the ammunition. Fire extinguisher (2A:10BC) observed to be fully charged, a smoke detector and carbon monoxide detector were present and were functioning during today's inspection. Applicant understands the home is to be free from smoking at all times. Applicant understands children are never to be left in a vehicle or unsupervised.

Page 1 of 3

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gigi Mai	TELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: SALAZAR, VICTORIA	FACILITY NUMBER: 304313603
	VISIT DATE: 06/12/2019

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
26
27
28
29
30
31
32

LPAs reviewed Pediatric CPR/First Aid certification (exp. 09/2020), and they are EMSA approved and current for the applicant. Current immunization information for pertussis, measles, and influenza were verified by LPAs. Rental agreement is on file. The LPAs advised of Affidavit Regarding Liability Insurance (LIC 282) if did not purchase liability insurance and to maintain the form in all children's files. LIC9149 Landlord consent is on file.

The LPAs advised the applicant to contact licensing for any changes of off limit areas, operation hours or change in phone number. In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training, Immunizations as required by SB 792 (pertussis, measles, and influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.

Individuals who are 18 years of age or older living or working in the home must be fingerprinted cleared prior to being present in the facility. LPAs reviewed Unusual Incident Report form and advised the applicant to contact Licensing Officer of the Day within 24 hours by phone or fax and complete the Unusual Incident Report (LIC 624B) within seven days. LPAs reviewed with the applicant of Title 22 regulations, requirements of disaster drills (documented every 6 months), posting requirements, children’s records, facility/staff records, mandated child abuse and injury/death reporting. The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.

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 licensing office within 30 days of providing IMS. The plan should describe the facility’s policies and procedures that ensure the proper safeguards are in place. 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

Page 2 of 3

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gigi Mai	TELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: SALAZAR, VICTORIA	FACILITY NUMBER: 304313603
	VISIT DATE: 06/12/2019

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
26
27
28
29
30
31
32

A Child Care Provider’s Guide to Safe Sleep packet, Safety Seat, Never Ever Shake a Baby information, Safe Sleep Regulation, and Effects of Lead Exposure were discussed and provided to the applicant. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov

The applicant was provided a copy of their appeal rights (LIC9058 12/15) 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. First level appeal is to Regional manager, address is above on the report. The applicant was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

This facility will need to correct the following prior to issue of a license and send proof of the corrections to the CCLD office within 30-days.

1) 8-hour Preventative Health Practices Certificate
2) Barricade rose bushes/Plants with thorns in backyard
3) Door knob cover for garage door
4) Fingerprint Clearance, TB test, and LIC508 for 2 residents

Page 3 of 3.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gigi Mai	TELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3