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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313789
Report Date: 08/11/2020
Date Signed: 08/11/2020 11:34:06 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:LUNA, ALEXISFACILITY NUMBER:
304313789
ADMINISTRATOR:LUNA, ALEXISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 315-2006
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:14CENSUS: 0DATE:
08/11/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant Luna Alexis TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Ketki Desai conducted an in -person announced pre-licensing inspection for a new Large Family Child Care home. LPA met with applicant Alexis Luna and the assistant Olimpia Ramirez, who guided analyst on a tour of the new home. Per applicant, family members residing in the home including the applicant are 3 adults and one minor only. The applicant is requesting a Large family childcare home license. Per applicant, operation hours will be Monday to Saturday, 6:00AM to 6:00PM, care and supervision shall be provided to children ages 1 months - 12 years of age.

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a single-story home that consists of 4 bedrooms, 2 restrooms, living room, kitchen, dining area, playroom, side yards, backyard and a garage. There is no stairway in the home.
Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. The home has a central Air /Heating system, the A/C unit is installed in the backyard. (Needs a barrier around it) There is an additional portable A/C unit in the day care area for children. There is a fireplace in the living are and it has been covered with a safe barrier.
Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant states (that there are no poisons on the premises). Applicant was advised that any poisons must be locked with a key or combination lock.

Based on the Facility Sketch submitted, areas off limits to children and parents are: Three bedrooms including Master bedroom with one full bathroom, living area, kitchen, garage and side yard. Applicant shall install a child safety gate across the kitchen making it inaccessible to children. Front yard is only used as an entrance to the home. Applicant was made aware to ensure all the doors of the bedrooms were to remain closed during childcare operating hours. Side yard is where the dogs are kept, it has a metal gate with a latch. Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
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: LUNA, ALEXIS
FACILITY NUMBER: 304313789
VISIT DATE: 08/11/2020
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Areas Designated for Day care activities: Children shall enter the home through the front entrance, upon entering, they shall walk through the living room, dining room, on the left-hand side there is an open door leading to the day care area. The designated Day care area was observed to have age appropriate toys and educational items for the children. The bathroom designated for day care use is in the hallway across the dining area, next to the master bedroom. The bathroom was observed to be safe and free of hazardous items. There is a cabinet under the sink and needs child safety lock. Bathroom was clean. Next to the bathroom is a bedroom designated for Day care use, the bedroom is ventilated and shall be used for Isolation purposes and if needed for napping time for younger infants.

OUTDOOR PLAY AREA: Backyard is designated for outdoor play area, it is fenced and has concrete flooring on the side and some patches of grassy area it is shaded, age appropriate outdoor toys were observed. Applicant shall place fencing across the planter area making it inaccessible and safe for outdoor play.



Per applicant, there are no, firearms, weapons or bodies of water on the premises.

The value on the 2A10BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable.

There are three pets in the home (1 bird (Blue berry) and 2 dogs (Huskies)) Bird cage is placed in the bedroom or living area inaccessible to children, while the two dogs are kept in the side yard inaccessible to children

There are toys available for children. Cots shall be used during napping time, linens and blankets shall be provided by the parents. Young infants shall use cribs and playpens.

Applicant states that she will provide snacks for children in care. Food brought from the children’s homes, those containers shall be labeled with child’s name and properly stored or refrigerated.

Applicant and the assistants have completed the required Health and Safety with Nutrition and Lead Poisoning component Training and Pediatric First Aid and CPR which expires on 6/27/22. There are first aid supplies available. Page 2
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: LUNA, ALEXIS
FACILITY NUMBER: 304313789
VISIT DATE: 08/11/2020
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The following was discussed with the applicant:
·Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately.
Civil Penalties will be assessed if not in compliance.

·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 certification and a valid criminal record clearance associated to the facility license.
·Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
·The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
Applicant was also made aware of the Child Advocacy program so she could receive the updated Quarterly reports and other information in a timely manner. ChildCareAdvocatesProgram@dss.ca.gov

Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.


Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
Fire and safety drills must be performed every six months and documented for review by the Department.
Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: LUNA, ALEXIS
FACILITY NUMBER: 304313789
VISIT DATE: 08/11/2020
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UPDATE: H&S 1597.622: Commencing September 1, 2016, 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.
The licensee has submitted proof of immunization's

UPDATE: Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com

Infant Care: Applicant states that she will care for infants. LPA advised the Applicant to sleep infants where they can always be directly supervised and advised against sleeping infants in a separate room. The Applicant states the following as a supervision plan for infants: The infants will sleep in the designated infant room where she will be providing supervision and they shall not be left unattended. LPA provided a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. Online copy can be downloaded at: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf



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
Incidental Medical Services (IMS):
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
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: LUNA, ALEXIS
FACILITY NUMBER: 304313789
VISIT DATE: 08/11/2020
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LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms:

CHILDREN FORMS/RECORDS - Children’s files must contain the following documents/information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), Consent/Verification for Nebulizer Care (LIC 9166), California School Immunization Record, Parent Notification for Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Acknowledgment of Receipt of Licensing Reports (LIC 9224).

FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records: As required in Title 22 Regulations 102416.1, Unusual incident/Injury Report (LIC 624B): Child Care Facility Roster (LIC 9040), Notice of Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108), Property Owner/Landlord Consent (LIC 9149), Property Owner/Landlord Notification Form (LIC 9149).

INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by Law to post the following:


Facility License (LIC 203), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parent’s Rights (PUB 394). A Notice of Site Visit (LIC 9213): Must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
 Handouts provided for Never Shake a Baby, Sudden Infant Death Syndrome (SIDS) and Safe Sleeping practices
 Capacity Handout for a Small Family Child Care Home and Large Family Child Care Home was provided.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: LUNA, ALEXIS
FACILITY NUMBER: 304313789
VISIT DATE: 08/11/2020
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Per applicant, there are no dual licenses at this address. Applicant’s email address was obtained during this inspection. The applicant was advised that email may be public information.

Following corrections are required before the final approval by the management
1) Install barrier around the A/C unit in the backyard
2)Install barrier across the planters in the backyard.
3) Install a child safety gate in the kitchen
4) Place child safety locks in the bathroom cabinet.

Applicant shall submit the above corrections by August 18th, 2020.


Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.


Exit interview was conducted with applicant Alexis Luna who agrees with the above.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
LIC809 (FAS) - (06/04)
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