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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627917
Report Date: 11/15/2021
Date Signed: 11/15/2021 05:23:10 PM

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:PAGAN, NINA FAMILY CHILD CAREFACILITY NUMBER:
376627917
ADMINISTRATOR:NINA PAGANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 940-8993
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:14CENSUS: 12DATE:
11/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Nina PaganTIME COMPLETED:
05:30 PM
NARRATIVE
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On November 15, 2021 at 1:15 p.m. Licensing Program Analyst (LPA), Leilani Curtis conducted an unannounced Annual Inspection and met with Licensee, Nina Pagan. LPA provided the LIC 126, Entrance Checklist to Licensee. Also present was the licensee’s helper Ann Naibova and spouse Mario Pagan. There were 12 children in care, one who is an infant. The infant who is the licensee's daughter was observed sleeping in a crib with a bumper pad, blanket and pillow. The facility was observed operating within ratio and capacity. LPA conducted a tour of the home inside and outside per facility sketch. Licensee is using the following areas for daycare: living room, dining area, kitchen, family room/day care room, bedroom #1, Bedroom #2, bathroom #1 and enclosed rear yard. Off-limits areas include: bedroom #3 (master bedroom) and bathroom #2 (located in master bedroom).

Licensee has provided adequate space for the children to eat, sleep and play within the home. Home is clean, orderly and has adequate ventilation. Children’s toys and play equipment are available and observed free of hazards. There are no stairs in the home. There is a working telephone/email address. LPA observed steak knives and screwdrivers accessible to children in kitchen drawers and medication and a butane gas canister on the kitchen counter. The fireplace is screened. The fire extinguisher and smoke and carbon monoxide detector are operational. Licensee states there are NO firearms or other weapons in the home. The outdoor play area is fenced and free of hazardous items. There are no existing bodies of water present. Children records were reviewed for Emergency Information. LPA reviewed 12 children files. Of the files reviewed 5 children did not have immunization records in file and four children did not have signed emergency information cards (LIC700). There are no new adults living or working in the home over the age of 18 years. All adult residents and helpers have submitted or been cleared for criminal record and child abuse index clearances or exemptions. The Licensee does not have a current Pediatric CPR and First-Aid certificate approved by the Emergency Medical Services Authority (EMSA). She has a non EMSA approved CPR/First Aid card that is valid through June 2023. LPA also discussed with Licensee AB 1207- Mandated Child Abuse Reporting. The licensee’s Mandated Reporter certificate expired 11/20/20. Renewal training can be taken at: www.mandatedreporterca.com. Immunization records per SB792 were reviewed and are in compliance.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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 8
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: PAGAN, NINA FAMILY CHILD CARE
FACILITY NUMBER: 376627917
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
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.

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. The licensee had knives, screwdrivers, medication and a butane gas canister accessible to children in the kitchen. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2021
Plan of Correction
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The licensee removed the hazardous items at the time of inspection.
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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 8
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: PAGAN, NINA FAMILY CHILD CARE
FACILITY NUMBER: 376627917
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child 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. The licensee does not have a disaster/fire drill log available for review. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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The licensee states that she will conduct and document a disaster/fire drill. The licensee will send LPA a copy of the disaster/fire drill log/documentation via email by POC due date of 11/22/21.
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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: PAGAN, NINA FAMILY CHILD CARE
FACILITY NUMBER: 376627917
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

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. An infant was observed sleeping in a crib which contained a bumper pad, blanket and pillow. This poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2021
Plan of Correction
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Licensee removed the bumper pad, blanket and pillow from the crib at the time of inspection.
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. The licensee does not maintain current mandated reporter certification. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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The licensee states that she will take updated mandated reporter training and send a copy of the completion certificate to LPA via email by POC due date of 12/10/21.
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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021
LIC809 (FAS) - (06/04)
Page: 4 of 8
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: PAGAN, NINA FAMILY CHILD CARE
FACILITY NUMBER: 376627917
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021

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 record review the licensee did not comply with the section cited above. The licensee does not have current CPR/First certification from an approved EMSA provider in file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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The licensee states that she will take CPR/First Aide training from an approved provider and send a copy of the completion certificate to LPA via email by POC due date of 12/10/21.
Type B
Section Cited
CCR
102418(g)
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.

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 5 out of 12 children did not have immunization records available for review. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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The licensee states that she will obtain immunization records for the 5 children and forward a copy of the records to LPA via email by POC due date of 11/22/21.
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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021
LIC809 (FAS) - (06/04)
Page: 5 of 8
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: PAGAN, NINA FAMILY CHILD CARE
FACILITY NUMBER: 376627917
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

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 4 out of 12 children did not have emergency information cards in the facility. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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The licensee states that she will obtain emergency information cards (LIC700) for the 4 children and forward a copy of the records to LPA via email by POC due date of 11/22/21.
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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021
LIC809 (FAS) - (06/04)
Page: 6 of 8
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: PAGAN, NINA FAMILY CHILD CARE
FACILITY NUMBER: 376627917
VISIT DATE: 11/15/2021
NARRATIVE
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This facility provides Incidental Medical Services – IMS. 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. Licensee will provide an IMS Plan of Operation to LPA by 11/30/21.

LPA reviewed the following with Licensee: Recently Approved Safe Sleep Regulations PIN 20-24-CCP, Updated Coronavirus 2019 Industry Guidance PIN 21-18-CCP, California Department of Public Health Guidance for Child Care Providers dated 6/29/21 and emergency drills. Licensee is reminded that corporal punishment, smoking, walkers, exersaucers, jumpers and bouncy seats shall never be permitted during daycare operation. Licensee is aware that interference with a child’s daily functions, corporal punishment, physical and mental abuse is not allowed. Licensee is reminded to make anything that reads, "Keep Out of Reach of Children" inaccessible to children. LPA also provided the following informational links about child development and children's behavior, food allergies, community resources and diversity and inclusion and equity:

https://www.cde.ca.gov/sp/cd/re/caqdevelopment.asp

https://theicn.org/icn-resources-a-z/food-safety

https://rrnetwork.org/about/what-we-do

https://www.cde.ca.gov/qs/ea/

See LIC809D for cited deficiencies.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
LIC809 (FAS) - (06/04)
Page: 7 of 8
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: PAGAN, NINA FAMILY CHILD CARE
FACILITY NUMBER: 376627917
VISIT DATE: 11/15/2021
NARRATIVE
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Child Care Providers can now sign up for Quarterly Updates and PINS through the DSS website. Please go to www.ccld.ca.gov and click on Child Care, go under Quick Links and Quarterly Updates, click on “Receive Important Updates” then enter your email address and choose which program(s) you would like to subscribe to and click “subscribe”.

Duty Officer: (619) 767- 2248, Monday thru Friday 8am-5pm.

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.

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.

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.

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

Exit interview conducted and report was reviewed with the licensee.

SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
LIC809 (FAS) - (06/04)
Page: 8 of 8