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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364842493
Report Date: 05/18/2022
Date Signed: 05/18/2022 05:12:14 PM


Document Has Been Signed on 05/18/2022 05:12 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 ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:FOSTER FAMILY CHILD CAREFACILITY NUMBER:
364842493
ADMINISTRATOR:FOSTER, LOLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 616-2431
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:14CENSUS: 5DATE:
05/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lola FosterTIME COMPLETED:
05:10 PM
NARRATIVE
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On 05/18/2022 at time listed above Licensing Program Analyst (LPA) Justin Giese made an unannounced visit to the facility for another purpose. LPA met with Licensee, Lola Foster and was granted access to the facility.

At 10:30am upon entering the facility LPA observed an infant child sleeping in the living room. The child was still fastened in their car seat with a half empty bottle of milk/formula sitting in their chest. Licensee did not move the child from the car seat to an appropriate crib or play yard. The facility was found to be in violation of the following Title 22 regulation:

102425(i) Infant Safe Sleep
(i) If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible. See LIC 809D for Type A citation

LPA provided Licensee Provider Information Notice (PIN) 20-24 Safe Sleep and discussed safe sleep regulations.

At 10:45am LPA requested to review records for staff working in the facility. Licensee was unable to produce a file or verify staff had appropriate paperwork. The facility was found to be in violation of the following Title 22 regulation:

102416.1(a) Personnel Records
(a) Personnel records shall be maintained on each employee... See LIC 809D for Type B citation
LPA provided Licensee with forms and documentation pertaining to maintaining staff files.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin GieseTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: FOSTER FAMILY CHILD CARE
FACILITY NUMBER: 364842493
VISIT DATE: 05/18/2022
NARRATIVE
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At 11:25am LPA requested to review files for children in care. Licensee stated the children had just enrolled and they had not received the completed paperwork from the children's parent/guardian. The facility was found to be in violation of the following Title 22 regulation:

102417(g)(7) Child's Records:
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.See LIC 809D for Type A citation

LPA provided Licensee with LIC700 Identification and Emergency Information form, LIC627 Consent For Emergency Medical Treatment and other documents pertaining to children's files at time of visit.

LPA issued a Notice of Site Visit and verified it was posted in a prominent location at the facility. Licensees understands that the Notice of Site Visit must remain posted for the next 30 days along with a copy of all Type A deficiencies cited during this inspection. A copy of all Type A deficiencies cited during this inspection must also be immediately (within 24 hours of child’s next day in care) given to the parents of all children enrolled in the child care facility and any children enrolled into the child care facility over the next 12 months (at the time of enrollment). Licensees are required to have all parents sign and date the Acknowledgement of Receipt of Licensing Reports (LIC9224) and maintain a copy in each child’s file. A copy of this report, LIC9224 and Appeal Rights (LIC9058) were provided during this inspection.

Exit interview conducted and report was reviewed with Licensee Lola Foster.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin GieseTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/18/2022 05:12 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 ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: FOSTER FAMILY CHILD CARE
FACILITY NUMBER: 364842493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2022
Section Cited

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102425 Infant Safe Sleep
(i) If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This was not met as evidenced by:
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Based on LPA observation, Licensee failed to move sleeping infant to crib or play yard, leaving them asleep in their car seat for a prolonged period of time. This is an immediate health and safety risk to children in care.
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The child woke up on their own and Licensee removed them from the car seat during visit. Licensee was provided PIN 20-24 at time of visit and will immediately adhere to its guidelines. POC cleared at time of visit.
Type A
05/19/2022
Section Cited

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102417(g)(7) Child's Records:
(7) An emergency information card shall be maintained for each child... and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This was not met as evidenced by:
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Based on LPA's Observation and interview, Licensee was unable to produce files for children. Licensee did not have emergency information or consent for medical treatment for children in care. This is an immediate health and safety risk to children in care.
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Licensee will collect signed LIC700, LIC627 and other applicable paperwork from children's authorized represenatives on of before the stated POC date. LPA will return to verify paperwork has been completed at a later 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: Gilbert SenaTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin GieseTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/18/2022 05:12 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 ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: FOSTER FAMILY CHILD CARE
FACILITY NUMBER: 364842493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2022
Section Cited

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102416.1 Personnel Records
(a) Personnel records shall be maintained on each employee...



This was not met as evidenced by:
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Based on LPA observation and interview, LIcensee failed to provide LPA with staff's Personnel records to review. This poses a potential health, safety, or personal rights risk to children in care.
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Licensee will gather necessary paperwork for staff files on or before the stated POC date. LPA provided Licensee with documents to achieve this task. LPA will review completed file on or defore POC date.

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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: Gilbert SenaTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin GieseTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4