393619809-5-30-2023-53-CC-CPRA-CSBS4S-20230530133312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 393619809
Report Date: 05/30/2023
Date Signed: 05/30/2023 01:33:23 PM

Document Has Been Signed on 05/30/2023 01:33 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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	HERNANDEZ, ELVIA & ANTONIO		FACILITY NUMBER:	393619809
ADMINISTRATOR:	HERNANDEZ, ELVIA & ANTONIO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 426-6244
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	14	CENSUS: 9	DATE:	05/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Licensee Elvia Hernandez		TIME COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/30/23, Licensing Program Analyst (LPA) Carla Polanco met with Licensee Elvia and Antonio Hernandez for the purpose of an unannounced annual inspection. Licensee's are Spanish speakers. There were nine children present at the start of inspection. Licensee's operating hours are Monday through Sunday, 23 hours a day. All adults subject to criminal background review have obtained criminal record clearance. 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. A health and safety inspection was conducted in all areas accessible to children. Off-limits areas are the sides of the yard. LPA observed the required postings and a working phone. 2A10BC fire extinguisher meets regulations. LPA observed smoke and carbon monoxide detectors, and verified they were both functional. LPA toured the kitchen area and verified knives were inaccessible to children in care. LPA observed age appropriate toys for children. LPA observed a restroom and verified that hazardous and toxic items were inaccessible to children in care. Licensee stated there are no weapons in the home. Outdoor front yard play area space is fenced. There are no bodies of water on the premises. *Continues on LIC809-C......*

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Carla Polanco Rivera	TELEPHONE: (916) 212-0752
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HERNANDEZ, ELVIA & ANTONIO	FACILITY NUMBER: 393619809
	VISIT DATE: 05/30/2023

NARRATIVE

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Children's files were reviewed. Emergency information and required immunization records were on file. LPA observed a current roster and documentation that a fire drill is conducted at least once every six months. Licensee's immunization records are available in the facility file. Current EMSA pediatric CPR and First Aid certification for Elvia was verified and expires 01/2025 and Child Care Provider Mandated Reporter certification was verified and expires 02/2024. Current EMSA pediatric CPR and First Aid certification for Antonio was verified and expires 08/2024 and Child Care Provider Mandated Reporter certification was verified and expires 02/2024.

Licensee provided copy of liability insurance which is $300,000 for every occurrence.

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.

LPA observed 15 min infant napping log for infants 24 months and under. LPA provided copies of LIC 9227 Individual Sleeping Plan for infants under 12 months.

This provider is currently providing Incidental Medical Services (IMS) to children in care. LPA reviewed storage of medication, and child personnel records. 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

Continues on LIC809-C......

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Carla Polanco Rivera	TELEPHONE: (916) 212-0752
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HERNANDEZ, ELVIA & ANTONIO	FACILITY NUMBER: 393619809
	VISIT DATE: 05/30/2023

NARRATIVE

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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at
https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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

Exit interview conducted and report was reviewed with the licensee. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today’s inspection.

SUPERVISOR'S NAME: Jeanne Smith	TELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Carla Polanco Rivera	TELEPHONE: (916) 212-0752
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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