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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628570
Report Date: 04/18/2022
Date Signed: 04/18/2022 12:49:46 PM


Document Has Been Signed on 04/18/2022 12:49 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108



FACILITY NAME:MARTINEZ, ELVIA FAMILY CHILD CAREFACILITY NUMBER:
376628570
ADMINISTRATOR:ELVIA MARTINEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 653-9129
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY:14CENSUS: 3DATE:
04/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Elvia MartinezTIME COMPLETED:
09:00 AM
NARRATIVE
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On April 18th, 2022 at 8:20 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted an unannounced case management inspection to issue a citation on a violation observed during a complaint investigation. LPA advised Licensee Elvia Martinez of the inspection’s purpose and she granted LPA facility entry. Present in the home was only the Licensee, Staff Elena Aquirre, two (2) daycare toddlers and one (1) daycare school aged child. Language Link Operator 13629 provided Spanish translation services.

The facility is licensed for 14 children. On 03/18/2022, Licensee left Staff 1 alone with ten (10) children while the Licensee conducted child transportations. (See LIC 811 Confidential Names). During this time, Child 1 left the facility without any adult daycare supervision.

Based on conducted interviews, it has been determined that the Licensee did not ensure that her large family childcare home reverted to capacity requirements for a small family childcare home when she left S1 alone with the ten (10) children. This deficiency is being cited per the California Code of Regulations, (Title 22, Division 12 & Chapter 3), and described on the attached LIC 809D.

Upon receipt, the Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. The Licensee shall also have parents complete and sign the Acknowledgement of Receipt of Licensing Report LIC 9224 (08/08); these signed forms will be made available to the Department upon request. LPA provided Licensee with a blank LIC 9224 form.

The Notice of Site Visit (LIC 9213) was provided to the Licensee, which is to be posted at the facility for 30 days. LPA observed form LIC 9213 posted. An exit interview was conducted with Licensee Elvia Martinez.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: MARTINEZ, ELVIA FAMILY CHILD CARE
FACILITY NUMBER: 376628570
VISIT DATE: 04/18/2022
NARRATIVE
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Appeal Rights (LIC 9098 01/16) along with a copy of this report was provided to the Licensee and their signature on this form confirms receipt of these rights.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/18/2022 12:49 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108


FACILITY NAME: MARTINEZ, ELVIA FAMILY CHILD CARE
FACILITY NUMBER: 376628570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited

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Staffing Ratio & Capacity - " ... If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home ..." This requirement is not met as evidenced by:

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On 3/18/2022, Staff 1 was alone with ten children. Based on conducted interviews and record reviews, the Licensee did not ensure staffing ratio & capacity requirements, which poses as an immediate risk to the health and safety of children in care.
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Licensee stated she will provide the Department a written statement summarizing what she viewed on the training video and a written statement on how she will ensure legal staffing ratio and capacity in the daycare; Licensee will provide LPA with this written statement no later than 04/29/2022.

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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: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
LIC809 (FAS) - (06/04)
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