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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334817151
Report Date: 05/04/2023
Date Signed: 05/04/2023 10:49:05 AM


Document Has Been Signed on 05/04/2023 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:MEDINA FAMILY CHILD CAREFACILITY NUMBER:
334817151
ADMINISTRATOR:MEDINA, EDITHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 755-1219
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:14CENSUS: 5DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Edith MedinaTIME COMPLETED:
11:00 AM
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· On 05/04/ 2023 at 8:15 AM Licensing Program Analyst (LPA) Giselle Carbullido arrived at the facility to conduct an annual inspection. LPA was granted entry by Licensee, Edith Medina. LPA toured the facility, inside and out, reviewed records, and observed and/or discussed the following: Normal days and hours of operation are Monday through Friday, 6:30am to 5:00pm
OFF-LIMIT AREAS INCLUDE: Second floor and garage
· The inspection consisted of reviews of the following domains: Physical Plant, Care and Supervision, Records, Facility Administration, Staffing Ratio and Capacity, Personal Rights The inspection found the facility to be in compliance in these domains, except as noted on the LIC809D. Deficiencies were cited this visit.
· The facility is operating within the licensed capacity and appropriate ratios
· The Licensee is present in the home and has ensured that children in care are supervised.
· When temporarily absent from the home, Licensee will arrange for a qualified, substitute adult to care for and supervise children
· A working telephone is present.
· Appropriate fire extinguisher- , smoke detector- and carbon monoxide detector- are present and were tested by the Licensee during this inspection. · All hazardous items are inaccessible which could pose a danger to children. See LIC809D
· Storage of poisons is inaccessible to children and locked
· There is a properly barricaded fire place- yes
· No guns or weapons present as stated by the Licensee. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 regulations.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 334817151
VISIT DATE: 05/04/2023
NARRATIVE
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 Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
· LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA Giselle Carbullido informed licensee Edith Medina that this report dated 05/04/23 document(s) 2 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Giselle Carbullido informed the licensee to provide a copy of this licensing report dated 05/04/23 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

· To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.



· A notice of site visit was given and must remain posted for 30 days.
· Exit interview conducted and report was reviewed with the licensee (Edith Medina).
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 334817151
VISIT DATE: 05/04/2023
NARRATIVE
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· Stairs are barricaded at this time: See LIC809D
· Home is clean and orderly with heating and ventilation for safety and comfort
· Safe and appropriate toys and equipment are present for both indoor and outdoor activities.
· Outdoor play areas are fenced and/ or appropriate supervision is present
· Verification of control of property on file: Yes
· Pediatric CPR and First Aid Card expired on 2021. See LIC809D Health & Safety Certificate - completed on 08/21/2005 Mandated reporter: Child Care Expired: 2021 See LIC809D Fire clearance: 12/18/2007 Documentation of fire & earthquake drills completed every six months: Last drill on 04/14/2023
· There are no bodies of water, at this time. Licensee understands all bodies of water must be properly covered or fenced per Title 22 regulations. The Department must be notified before and after installation of the above types of bodies of water. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Children’s files are complete- Yes. Staff files complete: See LIC809D.

· To receive important licensed- related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/04/2023 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 334817151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(3)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above in that stairs were not barricaded and children must pass to use bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Licensee replaced gate during this visit.
Type A
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review)], the licensee did not comply with the section cited above in that Licensee and Assistant do not have current CPR/First Aid. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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 Licensee will submit proof of enrollment for CPR/First Aid by POC due date 05/05/23.
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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 05/04/2023 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 334817151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) , the licensee did not comply with the section cited above in that cleaners, and other items (medications, lighters) which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Licensee removed lighters and made inaccessible; locked kitchen cabinet wih cleaners and will remove medications from higher cabinet prior to school age children arriving.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above in that Licensee acknowledged not implementing 15 minute safe sleep tracking which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Licensee will implement 15 minute tracking and submit proof of tracking to the department by POC due date. Sample 15 minute tracking sheet provided to Licensee.
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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 05/04/2023 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 334817151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited in that neither Licensee or Assistant have current Mandated Reporter certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2023
Plan of Correction
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Licensee will submit renewal mandated reporter certificates for themselves and assistant by POC due date 05/08/2023
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above in that the Assistant did not have immunizatons on file which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2023
Plan of Correction
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Licensee will submit proof of immunization for the Assistant by POC due date 05/08/23.
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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6