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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845044
Report Date: 05/25/2023
Date Signed: 05/25/2023 09:22:47 PM


Document Has Been Signed on 05/25/2023 09:22 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:MUNIZ-DEWOLF FAMILY CHILD CAREFACILITY NUMBER:
334845044
ADMINISTRATOR:MUNIZ-DEWOLF,APRILFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 652-7472
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:14CENSUS: 9DATE:
05/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:April Muniz-DewolfTIME COMPLETED:
03:23 PM
NARRATIVE
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On May 25, 2023, at 12:14 PM, Licensing Program Analyst (LPA) Anastasia Flores, 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 6:00 AM to 6:00 PM.

· Off-limit areas include: second story of house, garage, laundry room, family room, downstairs bedroom and pool area.

· The facility is licensed to have no more than 14 children as a large FCCH and is operating within the licensed capacity and appropriate ratios.


· Appropriate supervision provided during this inspection

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

· A fully charged fire extinguisher (2A:10BC) was observed. A smoke detector and carbon monoxide detector were present and tested by the Licensee during this inspection.

· All hazardous items are stored inaccessible to children

· Toxins are locked

· Weapons are not present as stated by licensee. 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

· Current roster on file

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

SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
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 6


Document Has Been Signed on 05/25/2023 09:22 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: MUNIZ-DEWOLF FAMILY CHILD CARE
FACILITY NUMBER: 334845044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Infant Safe Sleep
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 record review, the licensee did not comply with the section cited above in child #1 does not have immunizations on file at time of inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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child #1 does not have immunizations on file at time of inspection; Licensee will obtain immunization records and/or school enrollment forms for children in care that are missing their forms
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: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/25/2023 09:22 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: MUNIZ-DEWOLF FAMILY CHILD CARE
FACILITY NUMBER: 334845044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

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 two out of six childrens files do not have the LIC995A on file at time of inspection, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Licensee will obtain signed and completed forms from parents by 06/08/23 and send LPA Flores via email or text by 6/08/23
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

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 three out of six children's files do not have the LIC700 Emergency information on file at time of inspection.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Licensee will obtain signed and completed forms from parents by 06/08/23 and send LPA Flores via email or text by 6/08/23
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: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 05/25/2023 09:22 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: MUNIZ-DEWOLF FAMILY CHILD CARE
FACILITY NUMBER: 334845044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

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 child #1 does not have a sleep log on file at time if inspection. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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LPA Reviewed the infant safe sleep plan and regulations with llicensee and her spouse. LPA gave licensee a copy of what an infant safe sleep log looks like and she will begin the process as of 5/26/23. Licensee will send photo of infant safe sleep log to LPA Flores via email or text by 5/26/23.
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: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: MUNIZ-DEWOLF FAMILY CHILD CARE
FACILITY NUMBER: 334845044
VISIT DATE: 05/25/2023
NARRATIVE
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·Documentation of fire and disaster drills on file – Last drill conducted on 02/06/23

· In ground pool. Mesh fence- self-latching door. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains 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. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

· Verification of control of property on file

· Children’s records are incomplete

· Employee’s records are complete

· Mandated Reporter Training completed on 06/13/22

· Pediatric CPR and First Aid Card expire on 03/2025

· Health & Safety Certificate - completed on 03/15/2018


· 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

The Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov



The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.ca.gov
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: MUNIZ-DEWOLF FAMILY CHILD CARE
FACILITY NUMBER: 334845044
VISIT DATE: 05/25/2023
NARRATIVE
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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.
See 809D for deficiencies

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 a copy of this report, LIC809D’s appeal rights was reviewed and handed to licensee, April Muniz DeWolf on 5/25/23.



A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Anastasia FloresTELEPHONE: (951) 533-2031
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC809 (FAS) - (06/04)
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