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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313690
Report Date: 04/30/2020
Date Signed: 04/30/2020 04:25:39 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:AVALOS, MARIAFACILITY NUMBER:
304313690
ADMINISTRATOR:AVALOS, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 881-9266
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY:14CENSUS: 0DATE:
04/30/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Applicant Maria Avalos TIME COMPLETED:
04:30 PM
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Tele-Inspection
Licensing Program Analyst (LPA) Barajas, conducted an announced Pre-licensing Tele-Inspection of the facility on today's date with the applicant Maria Avalos using FaceTime. The LPA toured the facility via FaceTime with the applicant, Maria Avalos and Ivonne Avalos. Present during today's inspection was adult daughter Ivonne Avalos and Adult Brother Javier Villalobos, in off limit rooms. A review of criminal clearance records on this date indicates adults who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 5 adults including the licensee, Licensee Husband, Adult daughter, and 2 adult males and NO minor children living in the facility. Applicant stated will be caring for children ages 0-12 years old. Facility will be open 24 hours, 7 days a week. Ivonne Avalos, applicant’s daughter will be working as an assistant. Applicant stated is not currently not registered with any Foster Care agency or holds a foster parent license. Applicant was reminded if changes to notify the licensing office.

The facility is a single-story home with 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, laundry room, front yard, patio, backyard that is fenced and garage. Applicant stated front yard will be off limits as play area. LPA Barajas reminded applicant 100% visual supervision is always recommended due to front yard and front gate being so close to main street. The applicant has designated the living room, dining room, kitchen, both bathrooms, patio and backyard as part of her day-care. The applicant acknowledged the children may never enter the off-limit areas. Control of property was verified by LPA during today’s inspection via (rental agreement). The applicant has a cell phone that is used for childcare. The applicant was informed if a cell phone is used for childcare, it must always remain on the premises during hours of operation. Applicant was informed and understands the home is to be free from smoking during hours of operation.

The facility has a heater locked inaccessible to children in hallway. Facility has a fireplace closed covered with wood and television stand.
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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2020
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 4
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: AVALOS, MARIA
FACILITY NUMBER: 304313690
VISIT DATE: 04/30/2020
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Cleaning solutions/chemicals, utensils, and sharp knives located in the kitchen are all inaccessible by means of locks and safety gates. Poisons/Hazardous items are not stored on site, and none were observed. There is no body of water in the facility. The toys are age appropriate and in good condition for the potential ages served. Baby walkers, bouncers, jumpers, and similar items will not be used for children in care. The applicant stated there are no weapons or firearms on the premises. LPA advised when firearms are present, they must be locked and stored separately from the ammunition. During today's inspection, the smoke detector and carbon monoxide were operable, and the fire extinguisher was charged and in working condition. The fire alarm is installed in master bedroom.

EMSA approved PEDIATRIC CPR & PEDIATRIC First Aid are current for the applicant and expires on 09/28/2021 with Pediatric Plus. Applicant completed the 8-hour Preventative Health Practices and Nutrition Course with A-B-CPR on 10/13/2019. 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. Proof of immunization against pertussis, measles for Applicant and Assistant Ivonne Avalos were reviewed and within compliance. The applicant does not have proof of immunization against Influenza therefore provided declination letter. 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 Applicant and Assistant Ivonne Avalos provided Certificate of Completion dated 04/28/2020.

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 following was discussed with applicant: 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. LPA provided applicant with website for Live-Scan locations oag.ca.gov/fingerprints/locations for all adult complete LIC 9163.


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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: AVALOS, MARIA
FACILITY NUMBER: 304313690
VISIT DATE: 04/30/2020
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If adult is fingerprinted cleared and associated to another facility, licensee must submit a Criminal Record Transfer Request (LIC 9182) or Exemption Transfer Request form (LIC 9188). Contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182 or LIC 9188) with copy of a valid identification issued by State or Federal Government and Criminal Record Statement (LIC 508) to fax # (714)703-2831 prior to hiring adult. Failure to complete the clearance process or license association for any adult resident or assistant will result in a civil penalty assessment against the license.
LPA reviewed Unusual Incident Report (UIR) form (LIC 624B)-advised to contact Licensing Officer of the Day within 24 hours and complete the UIR within seven days by faxing LIC624B to (714)703-2831. LPA advised applicant to report to licensing any unusual incident or child absence that threatens the physical or emotional health or safety of any child or any changes to hours and days of operation and also for any changes to facility, including on/off limit areas and change in phone number.

LPA reviewed with applicant requirements of Disaster Preparedness drills (documented every 6 months). The LPA advised of Affidavit Regarding Liability Insurance (LIC 282) if did not purchase liability insurance and to maintain the form in the children's files, and Car Safety Seat pamphlet were discussed and provided to the applicant. Posting requirements which include but not limited to Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9141), Parents Rights (PUB 394), Notice of Site Visit (LIC 9213), and License (LIC 203). LPA reviewed with applicant the need to maintain records including but not limited to Children records and Staff/Adults records, (LIC 311D).

Department web site form was given to download forms, Title 22 regulations, and training's on-line at http://www.ccld.ca.gov. The applicant was also informed to visit the 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. LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

A copy of “A Child Care Providers Guild to Safe Sleep” was provided to applicant:


English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP:
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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: AVALOS, MARIA
FACILITY NUMBER: 304313690
VISIT DATE: 04/30/2020
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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 applicant 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 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

The applicant was given a pamphlet on Lead Exposure and was discussed with provider. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. 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 facility was in compliance for a LARGE Family Child Care Home with Title 22 Regulations at the time of tele inspection. A license will be issued after final review, in the event additional requirements are needed, the applicant will be notified.

Exit interview was conducted with Licensee via Tele-Inspection. Report was read and translated to Licensee in Spanish. Appeal rights was discussed with the applicant. The applicant was informed all appeals must be in writing and received by the licensing office within 15 business days. A copy of the report along with Appeal Rights will be email to Licensee with a Read Receipt to acknowledge report was received. If Read Receipt is not functional, Licensee will respond to email stating “I have read and received the report, I acknowledge receipt.” LIC 809” will also be mailed if those options are not available.



End of Report
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4