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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393616281
Report Date: 10/12/2023
Date Signed: 10/12/2023 06:03:53 PM


Document Has Been Signed on 10/12/2023 06:03 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MEDINA, EVANGELINAFACILITY NUMBER:
393616281
ADMINISTRATOR:MEDINA, EVANGELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 465-9028
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY:14CENSUS: 7DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Evangelina MedinaTIME COMPLETED:
06:30 PM
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Inspection was conducted in Spanish and is translated in English.

On 10/12/23 Licensing Program Analyst (LPA) Corina Beckby, conducted an unannounced annual inspection and met with Licensee, Evangelina Medina. (LIC126 SP), Entrance Checklist for Family Child Care Homes, was provided and reviewed with Licensee. Present in the facility was Licensee and assistant supervising 7 children including 2 infants. Facility hours of operation are Monday – Saturday 24 hours. LPA verified that annual fees are not current. Licensee stated she made payment on 10/9/23.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.



A health and safety inspection was conducted in all areas accessible to children. Upon entry, LPA observed the posting of the facility license, Emergency Disaster Plan, Earthquake Preparedness Checklist and Notification of Parent Rights. During today’s inspection, Licensee stated she wanted to make Bedroom 2 on limits and use it as a napping area. LPA inspected the room and verified it was safe for children. Bedroom #2 will now be on limits. Off-limit areas: Master bedroom, Master bathroom, Bedrooms 3 & 4, Bathroom located in bedroom 3, laundry room, second floor laundry room, right side of the backyard patio which leads to side driveway, and front yard. Off-limits areas will remain inaccessible to children by closed doors, gates, and/or supervision. The licensee acknowledges that she must contact LPA prior to making an off-limits area on-limits and vice versa.

Report continued on LIC809-C...
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MEDINA, EVANGELINA
FACILITY NUMBER: 393616281
VISIT DATE: 10/12/2023
NARRATIVE
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Cleaning agents and detergents are made inaccessible to children. Poison, toxic and hazardous times are made inaccessible to children. Functioning smoke and carbon monoxide detectors were observed in the home and meet Title 22 regulations. LPA observed a 3A40BC fire extinguisher that is serviced yearly. Sharp utensils are inaccessible to children. The backyard is fenced and has sufficient toys. The fireplace in the home has tempered glass. Personal medication is stored in a top cabinet in the kitchen. Licensee states there are no weapons in the home.

LPA did not observe a current roster nor disaster drill logs. Licensee understand drills must be conducted at least once every six months. LPA reviewed 8 children’s files. Preventative health and current pediatric CPR and first aid training was verified for Licensee, and CPR expires 03/31/25. Mandated Reporter Training certificate could not be verified. Licensee understands the training must be completed once every two years, and training is accessible at www.mandatedreporterca.com.

Licensee currently has 1child enrolled that require IMS. Licensee acknowledges that a Plan for Providing IMS must be submitted to the Department. 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.



Licensee has 2 infants currently enrolled. Licensee is not maintaining sleep logs for all infants in care (under 24 months) nor has Infant Individual Sleeping Plans for all infants under 12 months. LPA discussed the safe sleep regulations with Licensee and provided 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 provided example of safe sleep log and LIC 9227.

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.
Report continued on 809-C...

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MEDINA, EVANGELINA
FACILITY NUMBER: 393616281
VISIT DATE: 10/12/2023
NARRATIVE
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LPA encouraged Licensee to visit the department website at WWW.CCLD.CA.GOV for information regarding childcare updates, forms, regulations and legislation pertaining to family childcare homes.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

During the exit interview, the Licensee, Evangelina Medina, confirmed there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

In the areas that were evaluated, a Type A deficiency and 6 Type B deficiencies were cited during today’s inspection.

LPA informed Licensee, Evangelina Medina, that this report dated 10/12/2023, documents a Type A citation that is an immediate Health and Safety, or Personal Rights risk to persons in care. In addition, 6 Type B citations were issued that are a potential Health and Safety, or Personal Rights risk to persons in care. A separate 809D is issued for each deficiency. Upon receipt of a Type A deficiency, licensee shall post the report for 30 days, in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed Acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.
An Exit interview was conducted, and the report was reviewed with Licensee, Evangelina Medina. LPA posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2023 06:03 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MEDINA, EVANGELINA
FACILITY NUMBER: 393616281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, licensee did not comply with the section cited above in that her assistant who has lived with her for 5 days is not livescanned, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Assistant will get Livescanned with 24 hrs.
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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2023 06:03 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MEDINA, EVANGELINA
FACILITY NUMBER: 393616281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

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 in that Licensee did not record fire drills, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Licensee will conduct a fire drill and document the fire drill. LPA will return to verify drill was done by due date.

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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 5 of 15


Document Has Been Signed on 10/12/2023 06:03 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MEDINA, EVANGELINA
FACILITY NUMBER: 393616281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

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 Licensee did not have any documents except immunizations and ID for assistant, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Licensee will make a file for all assistants. LPA will make a return visit to verify file.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 8 children's files reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Licensee will review all files and receive all missing immunizations. LPA will return to verify children's files who are not school age, have immunization records
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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 6 of 15


Document Has Been Signed on 10/12/2023 06:03 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MEDINA, EVANGELINA
FACILITY NUMBER: 393616281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's 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).

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 8 children's files reviewed did not have LIC995A, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Licensee will review all children's files. LPA will provide LIC995A's to parents who are missing the form. LPA will return and verify all files have required form.
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 in which she did not have a current roster, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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LPA provided a new roster for Licensee, Licensee will complete and have the roster ready by due date. LPA will return to verify roster is complete.
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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 7 of 15


Document Has Been Signed on 10/12/2023 06:03 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MEDINA, EVANGELINA
FACILITY NUMBER: 393616281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 8 of 8 children's files reviewed did not have the liablility form, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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LPA provided required form. Licensee will provide forms to all parents have signed forms in children's files. LPA will return to verify,
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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