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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842209
Report Date: 06/22/2022
Date Signed: 06/22/2022 12:32:10 PM


Document Has Been Signed on 06/22/2022 12:32 PM - 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 STREET, STE 700
RIVERSIDE, CA 92501



FACILITY NAME:MARTINEZ SERENA FAMILY CHILD CAREFACILITY NUMBER:
334842209
ADMINISTRATOR:MARTINEZ SERENA, LORENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 285-5466
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY:14CENSUS: 9DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Lorena Martinez SerenaTIME COMPLETED:
12:40 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Alaina Wilburn arrived at the facility to conduct an annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:

Normal days and hours of operation are: Monday through Friday, 6:30am to 6:00pm

OFF-LIMIT AREAS INCLUDE: Second Floor, entry living room, garage, and side yard

· Appropriate supervision provided during this inspection

· A working telephone is present and the current number is on file

· Appropriate smoke detector, fire extinguisher and carbon monoxide detector present and were tested by the Licensee during this inspection.

· All hazardous items are stored inaccessible to children

· Toxins are locked

· Stairs are barricaded

· Weapons are not present according to Title 22. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

· Clean, safe and age appropriate toys

SUPERVISOR'S NAME: Stephanie HudakTELEPHONE: (951) 320-2021
LICENSING EVALUATOR NAME: Alaina WilburnTELEPHONE: (951) 255-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: MARTINEZ SERENA FAMILY CHILD CARE
FACILITY NUMBER: 334842209
VISIT DATE: 06/22/2022
NARRATIVE
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· Current roster on file

· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted

· Documentation of fire and disaster drills on file (May 24, 2022)

· There are bodies of water as of this date. There is an in-ground pool in the backyard. LPA observed the fencing to be in compliance with Title 22 regulations; the fence surrounding the pool, is at least five feet high, does not obscure the pool view and the gate swings away from the pool with the self-close and self-latching mechanism which is no more than six inches from the top of the gate. Applicant understands all bodies of water including ponds, above ground pools and spas, in-ground pools and spas, and some fountains must be properly covered or fenced per Title 22 regulations.

· Verification of control of property on file (mortgage statement)

· Employee’s records are complete

· Pediatric CPR and First Aid Card expires on 06/11/2024

· Mandated Reporter Training expired 01/29/2022

· Health & Safety Certificate completed on 04/21/2013


· Resident and/or staff records were reviewed and all adults who require caregiver background checks have received all required clearances and/or exemptions.

The licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

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: Stephanie HudakTELEPHONE: (951) 320-2021
LICENSING EVALUATOR NAME: Alaina WilburnTELEPHONE: (951) 255-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: MARTINEZ SERENA FAMILY CHILD CARE
FACILITY NUMBER: 334842209
VISIT DATE: 06/22/2022
NARRATIVE
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The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.ca.gov
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.

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.

Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.



The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.
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.

An exit interview was conducted, and this report was reviewed with the licensee Lorena Martinez Serena. Appeal rights were discussed and provided during the exit interview.



See LIC809-D for cited deficiencies

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

SUPERVISOR'S NAME: Stephanie HudakTELEPHONE: (951) 320-2021
LICENSING EVALUATOR NAME: Alaina WilburnTELEPHONE: (951) 255-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/22/2022 12:32 PM - 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 STREET, STE 700
RIVERSIDE, CA 92501


FACILITY NAME: MARTINEZ SERENA FAMILY CHILD CARE
FACILITY NUMBER: 334842209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Wilburn's record review, the licensee did not comply with the section cited above in 3 out of 8 children (C6, C7 & C8) did not have proof of required immunization's at time of visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Licensee will obtain current, required immunization's for C6, C7 and C8 and submit proof to LPA by plan of correction date of 07/22/2022.
Section Cited
Staffing Ratio and Capacity
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: Stephanie HudakTELEPHONE: (951) 320-2021
LICENSING EVALUATOR NAME: Alaina WilburnTELEPHONE: (951) 255-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 06/22/2022 12:32 PM - 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 STREET, STE 700
RIVERSIDE, CA 92501


FACILITY NAME: MARTINEZ SERENA FAMILY CHILD CARE
FACILITY NUMBER: 334842209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.5(b)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Wilburn's observation, the licensee did not comply with the section cited above in LPA observed 9 children, 1 is the licensee's child, in attendance with no qualified Assistant, which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee advised she was not aware her own child counted in the capacity requirements.
POC Due Date: 07/22/2022
Plan of Correction
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Licensee advised that she will have her child go to a family members home, when she has additional children in care. She will operate within the small family child care home regulation requirements, until she decides to hire an assistant.
Type B
Section Cited
CCR
102416.5(c)
Staffing Ratio and Capacity
(c) The total licensed capacity for a Small Family Child Care Home shall not exceed eight children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Wilburn's observation, the licensee did not comply with the section cited above in LPA observed 9 children, 1 is the licensee's child, in attendance with no qualified Assistant, which poses/posed a potential health, safety or personal rights risk to persons in care. Although the licensee is licensed as a large, because she doesn't have an assistant, she is supposed to comply with the regulation capacity requirements for a small family child care home.
POC Due Date: 07/22/2022
Plan of Correction
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Licensee advised that she will have her child go to a family members home, when she has additional children in care. She will operate within the small family child care home regulation requirements, until she decides to hire an assistant.

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: Stephanie HudakTELEPHONE: (951) 320-2021
LICENSING EVALUATOR NAME: Alaina WilburnTELEPHONE: (951) 255-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5