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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622596
Report Date: 09/28/2021
Date Signed: 09/28/2021 05:33:01 PM

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:HENRIQUEZ, ROXIANNEFACILITY NUMBER:
343622596
ADMINISTRATOR:HENRIQUEZ, ROXIANNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 545-2161
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:14CENSUS: 10DATE:
09/28/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Roxianne HenriquezTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Elimika Woods met with Licensee Roxianne Henriquez for an Unannounced Annual/Random Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present during the inspection were ten (10) children, nine (9) preschool age children and one (1) infant and three additional staff members. Licensee stated that the facility operates from 7AM to 5PM Monday to Friday .

LPA toured the facility to conduct a Health and Safety inspection. This two story home was clean and orderly, with heating and ventilation for the safety and comfort of children in care. The Isolation area will be a section of the family room, away from other children in care.

On- Limit areas are the: Kitchen, daycare room, dining room, bathroom downstairs next to bedroom (1), bedroom next to bathroom, family room

Off- Limit areas are the: Entire second level of home, laundry room, and garage

The off-limits are will be made inaccessible by closed and/or locked doors and visual supervision. There is a gate at the bottom of the stairs to prevent children five years and younger access.

There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today's inspection. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection.

The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, first aid kit, and telephone. There's a fireplace that is screened to prevent access by children. Per licensee, there are no firearms in the home. The licensee is in compliance with the immunization laws which pertains to all childcare providers.

See 809-C for continuance
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 229-4549
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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 4
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: HENRIQUEZ, ROXIANNE
FACILITY NUMBER: 343622596
VISIT DATE: 09/28/2021
NARRATIVE
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The OUTDOOR PLAY area is the fully fenced backyard and LPA observed that it is free from defects or dangerous conditions. During today's inspection, there are no play structures which are required to be anchored.

The licensee's Health and Safety training is completed, and CPR and First Aid certificate is current and expires 04/2022. The licensee has completed mandated reporter training and it expires on 01/28/23.

At 3:50 PM LPA requested and reviewed the files of five (5) children in care. All files contained Immunization, Parent's Rights, and Medical Consent forms. The facility roster was reviewed, and copies were obtained. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 09/22/21. The licensee is in ratio today. All required forms are posted and visible for public review.

California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.

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

See 809-C
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 229-4549
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: HENRIQUEZ, ROXIANNE
FACILITY NUMBER: 343622596
VISIT DATE: 09/28/2021
NARRATIVE
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LPA informed the licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The licensee was also reminded that CPR/First Aid is renewed every two years. Mandated Reporter Training is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Items that are not permitted in Licensed day-care facility: Infant bouncers, saucer chairs, johnny jumpers, baby walkers & drop-down cribs

Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.

The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. The licensee was provided information regarding effects of Lead Exposure and testing requirements (Assembly Bill 2370).

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.

See 809-C

SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 229-4549
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: HENRIQUEZ, ROXIANNE
FACILITY NUMBER: 343622596
VISIT DATE: 09/28/2021
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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.

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/inspection-process.

There are no defeciencies. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Roxianne Henriquez.

SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 229-4549
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4