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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334841590
Report Date: 10/15/2021
Date Signed: 10/15/2021 05:30:24 PM

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:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
334841590
ADMINISTRATOR:LOPEZ, ROSARIOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 722-7920
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:14CENSUS: 6DATE:
10/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Yesenia LopezTIME COMPLETED:
04:30 PM
NARRATIVE
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On 10/15/21 at 3:30PM, a case management visit was completed by Licensing Program Analyst (LPA) Giselle Carbullido during the course of another inspection at the facility. LPA was granted entry by Licensee, Yesenia Lopez. LPA toured the facility, reviewed records and took census.

Based upon LPA records reviews and per Licensee self-admissions: the following deficiencies were discussed:

1) Safe sleep documentation of 15 -minute checks is not in effect per CCR Title 22 Regulation. See technical advisory LIC9102TV.

2) Incomplete staff records: Mandated reporter and Immunizations. See LIC809D for deficiencies.

3) An uncleared adult has been working in the facility. See LIC809D. An immediate civil penalty of $500.00 was issued.

An exit interview was conducted, a copy of this report, appeal rights and Notice of Site Visit was provided to the Licensee; and the LPA observed the Notice of Site Visit form was posted. THIS REPORT MUST BE AVAILABLE TO THE PUBLIC UPON REQUEST FOR THREE YEARS.

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

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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 3
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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 334841590
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2021
Section Cited

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1596.8662(B)(1)Mandated Reporter :... a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training … and shall complete renewal mandated reporter training every two years following… This requirement is not met as evidenced by:
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Based upon record review facility did not have mandated reporter training certificates for S1 and S2. This poses a potential helath and safety risk for children in care.
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Type B
10/22/2021
Section Cited

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1597.622Health and Safety Code: SB 792 – Effective September 1, 2016, a person may not be employed or... at a family child care home unless he or she has been immunized against influenza, pertussis, and measles ... sections 1596.7995). This requirement is not met by evidence of:
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Based upon LPA record review facility did not have immunizations for review for S1. This poses a potential health and safety risk for 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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 334841590
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2021
Section Cited

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102416(d)(1) Personnel Requirements d) Prior to employment or initial presence in the child care home, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption... This requirement is not met as evidenced by:
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Based on LPA's interviews and per Licensee's own admission- Licensee did not have proof of criminal record clearance for adult niece working at the facility since September 2021. This poses an immediate health and safety risk to the children in care.
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A $500.00 civil penalty was issued

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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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle CarbullidoTELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3