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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364843501
Report Date: 01/08/2025
Date Signed: 02/07/2025 08:28:47 AM

Document Has Been Signed on 02/07/2025 08:28 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
364843501
ADMINISTRATOR/
DIRECTOR:		ANA HERNANDEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 835-7692
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 4DATE:
01/08/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:39 PM
MET WITH:Ana HernandezTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On date and time listed, Licensing Program Analysts (LPAs) Eric Ramos and Perla Ordones arrived at the facility to conduct an annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:
Normal days and hours of operation are: Monday through Friday 05:00 AM to 07:00 PM
Off-limit areas include: Bedroom 1 and Garage
· The facility is operating within the licensed capacity and appropriate ratios
· Appropriate supervision was provided during this inspection
· A working telephone is present, and the current number is on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· Fireplace is properly screened to prevent access by children
· All hazards/toxins/poisons are not locked and are accessible to children. During facility tour, LPAs observed several poisons/toxins present on top of the washer/dryer, in bedroom 2, and in the hallway cabinet which were areas accessible to daycare children.
· Weapons are not present. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· This is a single-story home
· Clean, safe and age-appropriate toys
· Current roster on file
· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights are posted
· Documentation of fire and disaster drills on file – Last drill conducted on 11/10/2024
· Mandated Reporter Training expires on 11/2026
· Pediatric CPR and First Aid Card expires on 03/2026
· Health & Safety Certificate - completed on 03/23/2003
*Report amended due to incorrect visit date*
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Eric Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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 10
Document Has Been Signed on 01/08/2025 05:00 PM - It Cannot Be Edited


Created By: Eric Ramos On 01/08/2025 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 364843501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)(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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

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 in that poisons/toxins were not key locked and were accessible to children in day care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2025
Plan of Correction
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Licensee agrees to move poisons/toxins to a key locked area and submit proof to Community Care Licensing by Plan of Correction (POC) date above.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ana Noble
LICENSING EVALUATOR NAME:Eric Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 01/08/2025 05:00 PM - It Cannot Be Edited


Created By: Eric Ramos On 01/08/2025 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 364843501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above in that S2 did not have a mandated reporter child care providers certificate on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Licensee agrees to have S2 complete the mandated reporter training and submit proof to Community Care Licensing by Plan of Correction (POC) date above.
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one out of four day care children's immunization records were not updated which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Licensee agrees to update C4's immunization record and submit proof to Community Care Licensing by Plan of Correction (POC) date above.
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:Ana Noble
LICENSING EVALUATOR NAME:Eric Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 01/08/2025 05:00 PM - It Cannot Be Edited


Created By: Eric Ramos On 01/08/2025 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 364843501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

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 record review, the licensee did not comply with the section cited above in that three out of four children's records were missing the LIC 995A which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Licensee agrees to have authorized representatives complete the LIC 995A for C1-C3 and submit proof to Community Care Licensing by Plan of Correction (POC) date above.

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:Ana Noble
LICENSING EVALUATOR NAME:Eric Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 01/08/2025 05:00 PM - It Cannot Be Edited


Created By: Eric Ramos On 01/08/2025 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 364843501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

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 that C4 was missing the fifteen minute sleep check log which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Licensee agrees to complete fifteen minute sleep check log for C4 and submit proof to Community Care Licensing by Plan of Correction (POC) date above.
Type B
Section Cited
CCR
102421(d)(1)

(1) The licensee shall maintain a completed and signed LIC 9150 (Rev. 8/14) Parental Notification Additional Children in Care, which is incorporated by reference, for this purpose.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that three out of four children's records were missing the LIC 9150 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Licensee agrees to have authorized representatives complete the LIC 9150 for C1-C3 and submit proof to Community Care Licensing by Plan of Correction (POC) date above.
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:Ana Noble
LICENSING EVALUATOR NAME:Eric Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 364843501
VISIT DATE: 01/08/2025
NARRATIVE
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·No bodies of water currently. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar products must be emptied immediately after use and stored in an upright position.
· Children’s records are not complete. During record review, LPAs observed C4 did not have updated Immunizations and was missing proof of 15 minute checks. Additionally, LPAs observed C1-C3 did not have LIC995A and LIC9150 on file. LPAs advised licensee to maintain proof of enrollment for school aged children in care.
· Employee’s records are not complete. During record review, LPAs observed S2 did not have mandated reporter training.
· The licensee provided proof of control of property.

Resident and/or staff records reviewed on 01/08/2025 indicate all adults who require caregiver background checks have received all required clearances and/or exemptions.

The following items were discussed with the Licensee during inspection:

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: http://www.ada.gov/childqanda.htm

The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Eric Ramos
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 364843501
VISIT DATE: 01/08/2025
NARRATIVE
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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.

During visit, LPAs observed that C4 wore a pacifier with a lanyard. LPAs did not observe C4 asleep during visit. 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.
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.

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.

***To access on-line Licensing forms & Regulations for a Family Child Care Home please visit: www.ccld.ca.gov
***The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Eric Ramos
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 364843501
VISIT DATE: 01/08/2025
NARRATIVE
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See LIC809-D for cited deficiencies

LPA Eric Ramos informed licensee Ana Hernandez that this report dated 01/08/2025 document(s) one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
LPA Eric Ramos also informed licensee Ana Hernandez to provide a copy of this licensing report dated 01/08/2025 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted, and this report was reviewed with licensee Ana Hernandez.

During the exit interview, licensee Ana Hernandez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.


***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
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Eric Ramos
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
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