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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313670
Report Date: 10/25/2019
Date Signed: 10/25/2019 09:50:30 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:GODINEZ, MARIAFACILITY NUMBER:
304313670
ADMINISTRATOR:GODINEZ, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 261-6015
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:14CENSUS: 0DATE:
10/25/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Maria GoninezTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Torrence conducted a pre-licensing inspection due to receiving an application on 09/11/2019 requesting a location change. The LPA toured the home with the applicant, Maria Godinez and Earvin Godinez, Assistant. Applicant have an additional assistant who was not present during this inspection. The applicant has requested to relocate her family child care from one address to another in the city of Brea. The family child care home operation hours will be Monday through Friday 6:30 AM to 6:00 PM. A review of adults' records 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 single-family home with four bedrooms, three bathrooms, living room, family room, dining room, kitchen, attached garage, front yard (not fenced), and fenced backyard. The home was clean, orderly, and was at a comfortable temperature. There is a fireplace in this home; which was covered by dry wall; inaccessible to children in care. Off limits areas are: family room, three bedrooms, two bathrooms, kitchen (applicant has locks; ensuring areas are inaccessible to the children in care), front yard (not fenced) and attached garage. The applicant acknowledged the children may never enter the off-limit areas. Per applicant, daycare areas are as follow: master bedroom/bathroom, living room, and backyard.

Cleaning solutions/chemicals, utensils, and sharp knives are all inaccessible. Applicant stated poisons/hazardous items are locked in the garage.

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. Fire extinguisher (3A:40BC) observed to be fully charged, a smoke detector and carbon monoxide detector were present and were functioning during today's inspection.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2019
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: GODINEZ, MARIA
FACILITY NUMBER: 304313670
VISIT DATE: 10/25/2019
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LPA reviewed the 16 hours Preventative Health, Pediatric CPR/First Aid certification (exp. 09/2021), and they are EMSA approved and current for the applicant. Current immunization information for pertussis, measles, influenza, and mandated reporter training were verified by LPA. Control of property was verified by LPA during today's inspection. Applicant has Liability Insurance.

The LPA advised the applicant to contact licensing for any changes of off limit areas, operation hours or change in phone number. The applicant has a cell phone that is used for child care. The applicant was reminded that if a cell phone is used, it must remain on the premises at all times during hours of operation. 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.

The following were discussed: 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. Individuals within one month of their 18th birthday must be fingerprinted immediately. If adult is fingerprinted cleared and associated to another facility, licensee must complete a Criminal Record Clearances or Exemption Transfer Request form (LIC 9182 or LIC 9188) with copy of ID and Criminal Record Statement (LIC 508) and fax to (714)703-2831 prior to hiring adult. Civil Penalties will be assessed if not in compliance.

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), LIC 311D posting requirements, children’s records, facility/staff records, mandated child abuse and injury/death reporting. LPAs explained to the applicant of children's rights, including no intimidation, humiliation, and no corporal punishment. The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2019
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: GODINEZ, MARIA
FACILITY NUMBER: 304313670
VISIT DATE: 10/25/2019
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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. LPA discussed with applicant that a plan must be submitted indicating that IMS services are being provided. The plan 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. Topics to be covered include but not limited to:
-Types of IMS to be provided (Blood Glucose Testing; Inhaled Medication; EPI-PEN; Glucagon; G-Tubes);
-Records and Authorizations; ·Storage; ·Staff training; ·Safety precautions; ·When to call 911 ·Reporting Requirements need to be in the plan. Refer to Title 22 Sections 102417 and Health and Safety Code Section 1596.750 and 1507. Technical assistance can be found at http://ccld.ca.gov/PG546.htm and http://ccld.ca.gov/PG2105.htm .

A Child Care Provider’s Guide to Safe Sleep, Never Ever Shake a Baby information, Safe Sleep Regulation, and Effects of Lead Exposure were discussed and provided to the applicant. 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 applicant was also informed to visit the http://ccld.ca.gov website for Quarterly Updates. 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. First level appeal is to Regional manager, address is above on the report. The licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

This facility meets licensing requirements on this date and a license for a large family child care home will be issued pending a final review. An exit interview conducted where the report was discussed and provided to the applicant. – END OF REPORT –


SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3