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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623873
Report Date: 03/08/2022
Date Signed: 03/08/2022 11:32:15 AM


Document Has Been Signed on 03/08/2022 11:32 AM - 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:JIMENEZ, MELINAFACILITY NUMBER:
343623873
ADMINISTRATOR:JIMENEZ, MELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 247-2530
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY:14CENSUS: 6DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Melina JimenezTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Amanda Blesi met with Licensee, Melina Jimenez, for the purpose of an unannounced required 1-year inspection. The licensee's mother in law and father in law were also present and assisting with the children today. All individuals subject to criminal background review have obtained a criminal record clearance. At 9:45 a.m. LPA observed a total census of 6 children including 2 infants over 12 months, and 4 preschool age children.

At 10:00 a.m., Licensee guided LPA on a tour of the facility, and a health and safety inspection was conducted in all areas accessible to children. Off-limits areas include master bedroom, downstairs in law residence and backyard area beyond the gated play area. Licensee acknowledged that children must never enter these areas. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. LPAs observed the outside play space to have a fenced pond containing water. The pond is surrounded by a wooden fence, which that is at least 5 feet high. Licensee explained that the pond fills up during winter with the water from the rain. Licensee stated that children don't play inside the pond area. LPA observed the gate to self-close and self-latch. LPA observed the latch was more than 6 inches from the top of the gate. During the inspection, the father in law was able to move the latch so that it was less than six inches from the top of the gate to meet regulation. There are no windows or doors that provide direct access into the pond area. Toxic and hazardous items are inaccessible to children. Stairs were barricaded at the top and bottom to prevent access when children under 5 are present. Outdoor play space is fenced.

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.
At 10:45 a.m., LPA reviewed children’s files and observed immunization records and emergency contact information. A current roster is being maintained and fire and disaster drills are documented.The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. The two assistants today did not have proof of immunization. Current CPR and First Aid certification was verified and expires 9/2022, and AB 1207 Mandated Reporter Training was verified for the Licensee and was expired in 2020 (Report continues LIC809-C)
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: JIMENEZ, MELINA
FACILITY NUMBER: 343623873
VISIT DATE: 03/08/2022
NARRATIVE
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LPA observed two play yards at the facility. Play yards contained blankets and toys. Children were not in the play yards. LPA reminded licensee that play yards must remain free of loose objects and licensee immediately removed all loose objects. Licensee stated she places infant children on their backs when they are napping. There were no infants in care under 12 months, therefore sleep plans were not reviewed.

LPA discussed the safe sleep regulations with licensee [or facility representative] 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 [facility representative] 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

LPA verified that the annual fees are current. 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided an updated Plan of Operation that includes 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


Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information.

Title 22 Deficiency has been cited on the attached LIC 809-D. Appeal Rights given.

Exit interview conducted and report was reviewed with the licensee Melina Jimenez. A notice of site visit was given and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/08/2022 11:32 AM - 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: JIMENEZ, MELINA
FACILITY NUMBER: 343623873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(5)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. (A)Fences shall be at least five feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as evidenced by: LPA measured the latch on the gate and it was located more than six inches from the top of the gate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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During the inspection today, licensee's father in law removed the latch and relocated to a position which was six inches from the top. The deficiency was corrected during the inspection.

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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 03/08/2022 11:32 AM - 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: JIMENEZ, MELINA
FACILITY NUMBER: 343623873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a children's record review and interview with licensee the above requirement was not met as evidenced by: licensee was not aware of the 15 minute sleep check for all infants under age two years old which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2022
Plan of Correction
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Licensee was provided a printed copy of the Title 22 Sleep regulations. To correct the deficiency, licensee shall provide proof that she is conducting 15 minute checks on all sleeping infants under age two. Licensee was advised these sleep logs must be maintained for 3 years.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not comply with the section cited above in 3 out of 3 persons caring for children today did not have a current Mandated Reporter Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2022
Plan of Correction
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Licensee shall submit current Mandated Reporter Certificates for: Licensee, mother in law, Zenaida, and father in law Candido. This shall be sent to LPA by plan of correction date of 3/22/22.

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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 03/08/2022 11:32 AM - 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: JIMENEZ, MELINA
FACILITY NUMBER: 343623873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This box is intentionally left blank. See below for deficiency.
POC Due Date: 03/29/2022
Plan of Correction
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Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 3 records reviewed did not contain proof of measles, pertussis or flu immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2022
Plan of Correction
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Licensee shall submit to LPA proof of immunization for measles, pertusis, and flu for Zenaid and Candido. This shall be done by 3/29/22 to correct the deficiency.

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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6