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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622596
Report Date: 09/06/2023
Date Signed: 09/06/2023 03:14:15 PM


Document Has Been Signed on 09/06/2023 03:14 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:HENRIQUEZ, ROXIANNEFACILITY NUMBER:
343622596
ADMINISTRATOR:HENRIQUEZ, ROXIANNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 545-2161
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:14CENSUS: 8DATE:
09/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Roxianne HenriquezTIME COMPLETED:
03:30 PM
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On 9/6/23, Licensing Program Analyst (LPA) Corina Beckby met with Licensee, Roxianne Henriquez, for the purpose of an unannounced annual inspection. Licensee and assistant were present supervising 10 daycare children including 4 infants. Facility hours of operation are Monday through Friday 7:15 am to 5:00pm. LPA verified the annual fees are current.

Licensee stated there are no new residents in the home. All adults subject to criminal background review have obtained criminal record clearance. Licensee [or facility representative] 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.

A health and safety inspection was conducted in all areas accessible to children. Offf-limits areas include the second floor, laundry room, garage, and left side of the yard. Off limit areas are being made inaccessible by closed doors, gates and supervision. Licensee acknowledged that children may never enter these off-limit areas. LPA observed the required postings and a working phone and 2A10BC fire extinguisher. LPA observed functioning smoke and carbon monoxide detectors. LPA toured the kitchen area and verified knives were inaccessible to children in care. Licensee stated there are no weapons. Licensee has 1 dog which is separated via a gates while inside. Dog is not in contact with daycare children.

Report continues on 809-C.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HENRIQUEZ, ROXIANNE
FACILITY NUMBER: 343622596
VISIT DATE: 09/06/2023
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LPA observed cleaning supplies and medications properly stored. LPA observed living room area with age-appropriate toys for children. The backyard is fenced and there were no bodies of water on the property. Licensee is responsible for ensuring all child proof locks and gates are secured and in working order. Licensee understands that prior to making alterations or additions to the home or grounds, the licensee shall notify the Department of the proposed changes.

5 Children's files were reviewed. Emergency information and required immunization records were on file. LPA observed a current roster and documentation that a fire drill is conducted at least once every six months. Licensee's immunization records are available in the facility file. Current EMSA pediatric CPR and First Aid certification was verified and expires on 2/22/24. Licensee has current Mandated Reporter Training Certificate that expires 3/1/25 and understands Mandated Reporter Training must be completed every two years starting January 1, 2018 and retain proof of completion in the facility file. The training can be found at: mandatedreporterca.com.

Licensee has 4 infants in care. 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 discussed the requirement to check and log infant napping every 15 minutes for infants under 24 months.

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 does not have children requiring IMS. 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/ Report continues on 809-C.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HENRIQUEZ, ROXIANNE
FACILITY NUMBER: 343622596
VISIT DATE: 09/06/2023
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. 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.

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

LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for childcare updates, current forms, legislation and regulation information.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. During the exit interview, License, Roxianne Henriquez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

NO deficiencies were cited during today's visit.

An exit interview was conducted, and report was reviewed with the licensee, Roxianne Henriquez. A copy of this report will remain on file for a period of three years for public review upon request. Licensee's signature on this form acknowledges receipt of this form. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC809 (FAS) - (06/04)
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