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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842133
Report Date: 10/24/2023
Date Signed: 10/24/2023 11:18:38 AM


Document Has Been Signed on 10/24/2023 11:18 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:PAVLICH FAMILY CHILD CAREFACILITY NUMBER:
334842133
ADMINISTRATOR:PAVLICH, AMANDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 314-8764
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY:14CENSUS: 5DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Licensee Amanda Pavlich TIME COMPLETED:
11:28 AM
NARRATIVE
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On 10-24-2023 and time listed above, Licensing Program Analyst (LPA) Steven Montoya arrived at the facility to conduct an annual inspection. LPA was granted entry by Licensee, Amanda Pavlich. LPA toured the facility, inside and out, reviewed records, and observed and/or discussed the following: Days and hours of operation are Monday- Friday, 7 am -6pm. OFF-LIMIT AREAS INCLUDE: Upstairs bedrooms (4), Loft, two bathrooms, laundry and garage.

The inspection consisted of reviews of the CARE tool domains. The inspection found the facility to be in compliance except as noted on the LIC809D. Deficiencies were cited this visit.

The facility is operating within the licensed capacity and appropriate ratios. Licensee is present in the home and appropriate supervision is provided: A working telephone is present. Appropriate fire extinguisher: smoke and carbon monoxide detectors are present and were tested by the Licensee during this inspection. All hazardous items are inaccessible which could pose a danger to children. Storage of poisons/toxins are locked in garage. Fireplace is properly screened. Stairs are properly barricaded. Facility is clean, orderly and has adequate heating and ventilation. Facility has safe and age-appropriate toys for both indoor and outdoor activities. Outdoor play area is fenced. Verification of control of property on file. Property owner/landlord notification and consent on file

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PAVLICH FAMILY CHILD CARE
FACILITY NUMBER: 334842133
VISIT DATE: 10/24/2023
NARRATIVE
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Pediatric CPR and First Aid Card expires on: 4-19-2024. Health & Safety Certificate was not observed. LIC809D. Mandated reporter: Child Care Expires: LIC809D Fire clearance: Documentation of fire & earthquake completed. Last drill on 7-10-2023 Children’s records are complete: 5 Employee records are complete: 3

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.

There are no bodies of water during this visit 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.



Additionally, the following was reviewed with Licensee.

- AB 1207 – Mandated Child Abuse Reporting: Child Day Care Personnel Training, beginning January 1, 2018 – Requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years.

- Effective January 1, 2017 – Children under 2 years of age shall ride in a rear-facing car seat unless the child weighs 40 or more pounds OR is 40 or more inches tall. For additional information regarding car seat laws see www.chp.ca.gov

Licensee provided the Unusual Incident Reporting email: UnusualIncidentReportsDO09@dss.ca.gov
The Duty Officer is available to answer questions Mon. – Fri. at 1-844-LET-US-NO (1-844-538-8766)
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PAVLICH FAMILY CHILD CARE
FACILITY NUMBER: 334842133
VISIT DATE: 10/24/2023
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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

MyChildCarePlan.org – Centers and Family Child Care Homes Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Licensee reports not providing IMS services.Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.



Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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-andresources/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.

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PAVLICH FAMILY CHILD CARE
FACILITY NUMBER: 334842133
VISIT DATE: 10/24/2023
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

During the exit interview, the LICENSEE Amanda Pavlich confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the licensee Amanda Pavlich.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/24/2023 11:18 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: PAVLICH FAMILY CHILD CARE
FACILITY NUMBER: 334842133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(6)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (6) Documentation of completion of training on preventative health practices as required by Section 102416(c).

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 [1] out of [1] Licensee was not observed. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee will completed and submit Preventative Health and Safety Certificate to LPA Montoya via email: Steven.Montoya@dss,ca,gov.
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

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 [1] out of [1] [(records review) (C3)] which poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee will completed and submit Infant Safe Sleep plan to LPA Montoya via email: Steven.Montoya@dss,ca,gov.
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: Steven MontoyaTELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 10/24/2023 11:18 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: PAVLICH FAMILY CHILD CARE
FACILITY NUMBER: 334842133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1596.8662(b)(1)
Availability of information regarding detecting and reporting child abuse and neglect; training for mandated reporter who is licensed day care provider, administrator, or employee of a licensed child day care facility; proof of completion.

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 [2] out of [2)] [Mandated Reporting Cert) (Licensee and Assistant] [L1 and L2] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee will completed and submit Mandated reporting certificate to LPA Montoya via email: Steven.Montoya@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Steven MontoyaTELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6