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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376622868
Report Date: 01/13/2020
Date Signed: 01/13/2020 10:21:32 AM

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:HENRIQUES, SIMONE FAMILY CHILD CAREFACILITY NUMBER:
376622868
ADMINISTRATOR:SIMONE HENRIQUESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 994-2642
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY:14CENSUS: 7DATE:
01/13/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Simone HenriquesTIME COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Elise Read conducted an unannounced inspection with the Licensee. The home was toured and inspected to ensure an environment safe for the care and supervision of children. Present were the Licensee, helper Bianca Henriques, and 7 day care children.

The carbon monoxide detector/smoke detector combination (located in the living room) meets requirements is are operational. The fire extinguisher (located in the kitchen) meets regulation and is operational. All hazardous items were latched/locked and secured out of reach of children. There are no bodies of water on the property. Licensee states that there are no weapons in the home.

A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. First Aid and CPR certification expire on 07/2020. Licensee meets immunization requirements per SB 792 and has completed Mandated Reporter Training AB 1207. Children’s records do not have completed immunization records. Licensee maintains a current roster. Licensee is not conducting disaster drills per regulation.

Licensee has provided adequate space for the children to eat, sleep and play within the home. The licensee has sufficient toys and equipment available. Areas used for child care include entire home, except garage and bedroom #2. Off limits areas include garage and bedroom #2, which are inaccessible through use of door locks. The home has a fenced backyard available for outdoor activities.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Elise ReadTELEPHONE: (619) 767-2240
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2020
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 3
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: HENRIQUES, SIMONE FAMILY CHILD CARE
FACILITY NUMBER: 376622868
VISIT DATE: 01/13/2020
NARRATIVE
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Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, ensure that all adults living or working in the home have criminal background clearances to avoid civil penalties associated with this requirement. Corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. Licensee was also provided handouts with information regarding Safe Sleep and Lead Exposure. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA discussed and provided licensee with the following: Child Care Advocates - email address childcareadvocatesprogram@dss.ca.gov. In addition, for common questions or questions regarding licensing requirements to contact the Child Care Licensing duty line at 619-767-2248.

This facility provides Incidental Medical Services – IMS. Licensee will submit IMS plan to Department within 30 days. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

Please see LIC 809D for cited deficiencies.

An exit interview was conducted with the licensee. The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. LPA provided notice of site visit and observed it being posted at the facility.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Elise ReadTELEPHONE: (619) 767-2240
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: HENRIQUES, SIMONE FAMILY CHILD CARE
FACILITY NUMBER: 376622868
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2020
Section Cited

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Operation of a Family Child Care Home- Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement was not met as evidenced by:
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Based on record review, licensee did not ensure that she was conducting disaster drills per regulation, which poses a potential Health, Safety, or Personal Rights risk to children in care.
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Type B
02/14/2020
Section Cited

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Immunizations- The licensee shall document each child's immunizations...and shall maintain such documentation for as long as the child is enrolled. This requirement was not met as evidenced by:
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Based on record review, licensee did not ensure to have completed immunization records for each child enrolled, which poses a potential Health, Safety, or Personal Rights risk to children in care.
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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: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Elise ReadTELEPHONE: (619) 767-2240
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2020
LIC809 (FAS) - (06/04)
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