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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370810018
Report Date: 03/11/2022
Date Signed: 03/15/2022 09:31:38 AM


Document Has Been Signed on 03/15/2022 09:31 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108



FACILITY NAME:AGNEW, ROSA M. FAMILY CHILD CAREFACILITY NUMBER:
370810018
ADMINISTRATOR:AGNEW, ROSA M.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 292-2004
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:14CENSUS: 10DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Rosa AgnewTIME COMPLETED:
05:00 PM
NARRATIVE
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On 03/11//2022, at 1:40 PM Licensing Program Analyst (LPA), Dana Stevens conducted an unannounced Annual Required Inspection and met with the Licensee, Rosa Agnew. LPA disclosed the purpose of the inspection and was granted entry into the facility. The Licensee's daughter, son-in-law, and 10 children (ages:10 months, 2,3,3,4,5,5,6,8 and 10 years) were present during this inspection. The following areas used for child care are: Living Room, Kitchen, two bedrooms and one bathroom. Off-limits areas are garage, and entire upstairs. These areas are made inaccessible with door locks and a safety gate.

The fire extinguisher. Smoke detector, and carbon monoxide detector met requirements.  All hazardous items were made inaccessible to children. The licensee has toys, play equipment and materials available. Licensee stated there are no weapons in the home. Applicant stated she has completed Mandated Reporter training but her daughter/assistant has not. Licensee's and assistant's Pediatric CPR and First Aid certifications were expired. Required documents are posted. Children's records were reviewed and found complete. Licensee did not have a complete and updated roster.



Licensee verbally confirmed that her daughter and son-in-law are living in the home since September 2022. Licensee stated she did not report this change of household composition to the department because her daughter has lived with her previously. As of this date, Licensee's son-in-law has not been fingerprinted and background checked. 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.

There is one crib or play yard for each infant who is unable to climb out of the crib or play yard.  Cribs or play yards are free from all loose articles and objects. Licensee stated she physically checks on sleeping infants during naptime but has not been documenting the checks on a Sleep Log. Licensee did not have an Individual Infant Sleeping Plan [LIC 9227 (3/20)] for the one infant under 12 months of age.  The provider places infants up to 12 months of age on their backs for sleeping.
SUPERVISOR'S NAME: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Dana StevensTELEPHONE: (619) 767-2238
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: AGNEW, ROSA M. FAMILY CHILD CARE
FACILITY NUMBER: 370810018
VISIT DATE: 03/11/2022
NARRATIVE
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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.

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



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.

Deficiencies cited. Civil Penalty assessed.

Exit interview conducted and report was reviewed with the licensee.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Dana StevensTELEPHONE: (619) 767-2238
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/15/2022 09:31 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108


FACILITY NAME: AGNEW, ROSA M. FAMILY CHILD CARE
FACILITY NUMBER: 370810018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee interview, and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2022
Plan of Correction
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Licensee will provide proof her son-in-law has submitted LIVESCAN fingerprints for background clearance by 03/14/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Dana StevensTELEPHONE: (619) 767-2238
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 03/15/2022 09:31 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108


FACILITY NAME: AGNEW, ROSA M. FAMILY CHILD CARE
FACILITY NUMBER: 370810018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, and licensee interview, licensee did not comply with the above regulation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2022
Plan of Correction
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Licensee will begin documenting daily sleep logs for infants under 2 years of age and provided LPA with copy of current sleep logs by 04/11/2022.
Type B
Section Cited
HSC
1596.8662(c)
Administration of Child Day Care Licensing
(c) Current proof of completion for each licensed child day care provider or applicant for that license, administrator, and employee of a licensed child day care facility shall be submitted to the department upon inspection of the child day care or upon request by the department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on licensee interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2022
Plan of Correction
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Licensee will provide LPA with copies of Mandated Reporter Training certification for herself and all childcare assistants by 04/11/2022.

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: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Dana StevensTELEPHONE: (619) 767-2238
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 03/15/2022 09:31 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108


FACILITY NAME: AGNEW, ROSA M. FAMILY CHILD CARE
FACILITY NUMBER: 370810018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, llicensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2022
Plan of Correction
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Licensee will provide LPA with proof of completion of or registration for Pediatric CPR/First Aid renewal for herself and all childcare assistants.
Type B
Section Cited
CCR
102416.2(a)(2)
Reporting Requirements
(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (2) Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Licensee interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2022
Plan of Correction
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Licensee will submit to department an updated LIC279 and LIC279b, listing all adults and minor children living in the home by 04/11/2022.

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: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Dana StevensTELEPHONE: (619) 767-2238
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 03/15/2022 09:31 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108


FACILITY NAME: AGNEW, ROSA M. FAMILY CHILD CARE
FACILITY NUMBER: 370810018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

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 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2022
Plan of Correction
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Licensee will provide to LPA a copy of a current roster of all enrolled children by 04/11/2022.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2022
Plan of Correction
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Licensee will provide LPA with copy of LIC 9227 for infants under 12 months by 04/11/2022.

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: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Dana StevensTELEPHONE: (619) 767-2238
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6