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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313708
Report Date: 12/06/2019
Date Signed: 12/06/2019 03:14:18 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:CHAVEZ, MARIAFACILITY NUMBER:
304313708
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
12/06/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria Chavez, LicenseeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Yesenia Villa conducted an announced Prelicensing inspection of the facility on today's date. The LPA toured the facility with the applicant, Maria Chavez. This is a change of location Prelicensing inspection from LIC#304313266. 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 3 adult residents and 1minor child that visits the home on occasions: There are no assistants. Applicant stated she is not currently 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, and backyard that is fenced. The applicant has designated the family room located past the dinning room, the first bedroom to the right when entering the hallway and the restroom located in the hallway. The backyard will also be used as part of the day-care as stated by applicant. Applicant has placed the following areas as off-limit areas for the children; the three bedrooms in the home, the dinning area, kitchen, living room and restroom located in the master bedroom.

The applicant acknowledged the children may never enter the off-limit areas and has door knob locks on all of the bedroom doors. Control of property was verified by LPA during today’s inspection via a mortgage invoice.

The applicant has a cell phone that is used for child care. The applicant was informed if a cell phone is used for child care, it must remain on the premises at all times during hours of operation. Applicant was informed and understands the home is to be free from smoking during hours of operation.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 293-9465
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019
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: CHAVEZ, MARIA
FACILITY NUMBER: 304313708
VISIT DATE: 12/06/2019
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The facility does not have a wall heater, the home has central heating and air. The home has a fireplace in the living room that is not barricaded. Applicant will submit photos when the fireplace is barricaded as stated under Title 22 Regulations, 102417 Operations of a Family Child Care Home. Cleaning solutions/chemicals, utensils, and sharp knives located in the kitchen are all inaccessible by means of safety latches. The knives were observed to be made inaccessible in a drawer up high. Poisons/Hazardous items are not stored on site, and none were observed. There is a body of water in the front garden of the home which does not meet Title 22 regulations 102417(g)(5). The applicant plans on not using the fountain and states will place rocks inside and send pictures to the Department upon doing so.

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. 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.

EMSA approved (PEDIATRIC) CPR & (PEDIATRIC) First Aid are current for the applicant and expires on 11/13/21. Applicant completed the 8- Hour Preventative Health Practices and Nutrition Course on 12/17/2017.

The applicant will provide IMS. This facility plans to provide Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.htmThe 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 provide applicant with website for Live-Scan locations oag.ca.gov/fingerprints/locations for all adult complete LIC 9163. 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).

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 293-9465
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019
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: CHAVEZ, MARIA
FACILITY NUMBER: 304313708
VISIT DATE: 12/06/2019
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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).

Applicant was informed she is exempt from completing the Mandated Reporter Training for self and if any assistants that are bilingual are hired, they are required to complete the training. Department web site form was given to down load forms, Title 22 regulations, and trainings 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.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 293-9465
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019
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: CHAVEZ, MARIA
FACILITY NUMBER: 304313708
VISIT DATE: 12/06/2019
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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: 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 following was observed and needs correction before a license can be issued:



1.) The water fountain will become inoperable and applicant states she will fill with rocks, a picture will be submitted to the Department.

2.) The fire place in the living room must be screened. Licensee will send a picture to the Department once it is covered.

3.) LIC508 of all adults residing in the home.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 293-9465
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019
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: CHAVEZ, MARIA
FACILITY NUMBER: 304313708
VISIT DATE: 12/06/2019
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 Proof of corrections, such as, pictures by due date of 12/13/19. If an extension is needed, please submit a letter in writing before the due date. A license will be issued after final review, in the event additional requirements are needed, the applicant will be notified.

Appeal Rights and the appeal rights process 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.

An exit interview was conducted with applicant Maria Chavez at the applicant’s home, at the dinning table. 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.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 293-9465
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019
LIC809 (FAS) - (06/04)
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