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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313670
Report Date: 08/17/2021
Date Signed: 08/17/2021 03:24:12 PM

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: 4DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Lourdes Godinez, LicenseeTIME COMPLETED:
12:00 PM
NARRATIVE
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An Annual Required inspection was conducted at the facility by Licensing Program Analyst (LPA) Rivas. LPA observed Licensee, Ms. Maria Lourdes Godinez, caring for 4 children, which included 2 infants and 2 pre school age children. Assistant arrived shortly. Licensee was operating within the licensed capacity as specified on license.

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 4 adults including the licensee and 0 minor child living in the facility. Facility Day Care hours are 6:30am – 6:00pm, Monday through Friday.

During today’s inspection, LPA and licensee toured the facility inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of lock doors and gates. The Childcare area consists of the entry way, the living room, master bedroom and bathroom. Licensee reports children do not use master bedroom for napping, only to walk into bathroom. The day care area had age appropriate equipment and supplies and free of hazards. There is an outside play area which is accessed through living room/main day care area.

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.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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 5
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: 08/17/2021
NARRATIVE
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The home has age appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service). Licensee stated the backyard is used for outdoor play, the backyard was observed to be fenced, shaded and with age appropriate toys. There are no bodies of water on the premises.

The licensee has a current roster of children in care. There are currently 8 children enrolled. Four children’s records were reviewed for LIC700 and Immunization's and were found to be in compliance. The licensee and assistant both have valid CPR/First Aid certifications with an expiration date of 09/2021.

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’s provider mandated reporter was completed and expires on 09/30/2021.She will submit the general training certificate to LPA Rivas by 09/17/21. A technical advisory was issued for this requirement.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual . 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 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.



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.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 08/17/2021
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A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.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
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

LPA reviewed with licensee the following safe sleep best practices:


· 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 if 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.

In order to update facility file Licensee is to provide copies of;
Emergency Disaster Plan (LIC 610a)
Mandated Reporter Training
Statement Acknowleding Requirement to report Child A buse (LIC 9108)
Current Children in Your Home (lic279b)
Current copy of First Aid, CPR Lead training
Copy of Preventative Health And Safety Training

Items to be sent by September2
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 08/17/2021
NARRATIVE
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The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: Operation of a Family Child Care Home 102425(c) Infant Safe Sleep. (see LIC 809D).
Inspection, report reviewed and exit interview was conducted in Spanish with licensee.

An exit interview conducted with licensee Ms. Gondinez in Spanish. 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. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. 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.


End of Report
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2021
Section Cited

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Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.This requirement was not met as evidenced by LPA review of 4 children
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files. Two of the four requiring the plan did not have a plan in place. Licensee reported she was unaware of the requirement. This poses a potential risk to children in care.
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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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5