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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343621704
Report Date: 04/26/2022
Date Signed: 04/26/2022 03:25:20 PM


Document Has Been Signed on 04/26/2022 03:25 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:ALVAREZ, JESSICAFACILITY NUMBER:
343621704
ADMINISTRATOR:ALVAREZ, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 671-9104
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:14CENSUS: 12DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Jessica AlvarezTIME COMPLETED:
03:35 PM
NARRATIVE
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On 4/26/22 Licensing Program Analyst (LPA) Fabiola Diaz met with licensee Jessica Alvarez for unannounced annual/1 year inspection. During the inspection there were 12 day care children, two of which were infants. Licensee's daughter was assisting on today's date. All individuals subject to criminal background review have obtained a criminal record clearance.

The home is a one story home with a unfenced front yard, 4 bedrooms, 2 bathrooms, kitchen, living room, dining room, garage, and fenced backyard. The off-limit areas were updated today to: all bedrooms, garage, and left half of backyard. Licensee was notified that prior to any changes of an on-limit to an off-limit area, or vice versa, the department must be notified.

A health and safety inspection was conducted in the areas accessible to children. The house has a working telephone, fully charged fire extinguisher, and working smoke detector and carbon monoxide detector. Licensee stated that the Carbon Monoxide detector is part of her house alarm. Licensee stated there are no weapons in the home. LPA observed all the required postings. LPA advised the licensee that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. LPA did not observe bodies of water on premises.

Licensee's immunization records were discussed. Children's roster and a fire drill log were discussed. Licensee explained that she did a fire drill at the beginning of the year, but has no documentation of it. A Advisory Note was assessed. Licensee's CPR/First aid card had an expiration date of 2/11/23. Mandated Reporter Training for licensee was not observed. Licensee explained that she took it, but hasn't been able to acquire her certificate. An Advisory Note was assessed. Licensee understands training must be completed every two years. LPA observed children's files missing several LIC forms, including the LIC995A form. A type B citation was assessed.
Report continues on 809C................
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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 5


Document Has Been Signed on 04/26/2022 03:25 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833


FACILITY NAME: ALVAREZ, JESSICA
FACILITY NUMBER: 343621704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives 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). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of 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 observation and record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. Licensee did not ensure to have all of the children's files complete. Some files were missing form LIC995A.
POC Due Date: 05/26/2022
Plan of Correction
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Licensee will submit one complete child's file to LPA by POC due date.

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: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: ALVAREZ, JESSICA
FACILITY NUMBER: 343621704
VISIT DATE: 04/26/2022
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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

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.

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.

Licensee was reminded that all adults 18 and over, 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.

Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days. Exit interview was conducted and report was reviewed with the licensee. See Type B deficiency on LIC809-C.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC809 (FAS) - (06/04)
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