393622862-1-25-2023-53-CC-TDIP-CNF36X-20230125165904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 393622862
Report Date: 01/25/2023
Date Signed: 01/25/2023 05:00:51 PM

Document Has Been Signed on 01/25/2023 05:00 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME:	LEYVA, CAROLINE		FACILITY NUMBER:	393622862
ADMINISTRATOR:	CAROLINE LEYVA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 601-2601
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	14	CENSUS: 5	DATE:	01/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Caroline Leyva		TIME COMPLETED:	05:15 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 01/25/2023 at 1:00 PM, Licensing Program Analyst (LPA) Tiffanie Diep and Licensing Program Manager (LPM) Jeanne Smith met with Licensee, Caroline Leyva, for the purpose of an unannounced annual inspection. LPA and LPM were accompanied by Licensee during the inspection. There was one staff and five children present at the time of inspection, three of whom were infants. Licensee's operating hours are Sunday through Saturday from 4:30 AM to 4:30 PM. 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 include the master bedroom and garage. 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 playroom area with age-appropriate toys for children. LPA observed a fireplace that was barricaded by a metal screen. LPA observed a cleaning solution on the dining table and medications in a storage closet accessible to children in care. Licensee stated there are no weapons in the home. There are no bodies of water on the premises. Outdoor play space is fenced. Continues on 809-C

SUPERVISOR'S NAME: Chayntel Hunter	TELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Tiffanie Diep	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: LEYVA, CAROLINE	FACILITY NUMBER: 393622862
	VISIT DATE: 01/25/2023

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 was verified and expires 06/2024 and Child Care Provider Mandated Reporter certification was verified and expires 05/2024.

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 discussed the requirement to check and log infant napping every 15 minutes for infants 24 months and under. LPA provided a copy of the LIC 9227, Individual Sleeping Plan, for infants under 12 months.

This provider is not currently providing Incidental Medical Services (IMS) services to children in care. IMS policy was discussed.

For IMS information, see PIN 22-02-CCP. 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 809-C

SUPERVISOR'S NAME: Chayntel Hunter	TELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Tiffanie Diep	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: LEYVA, CAROLINE	FACILITY NUMBER: 393622862
	VISIT DATE: 01/25/2023

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A deficiency is being cited on the attached LIC 809-D pages. LPA informed Licensee that this report dated 01/25/2023 documents one Type A citation which shall be posted for 30 consecutive days as there was an immediate risk to the health, safety, or personal rights of children in care.

LPA informed Licensee to provide a copy of this licensing report dated 01/25/2023 that documents the Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed LIC 9224, Acknowledgement of Receipt of Licensing Reports, must be placed in each child's file for verification.

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 e-mail communication. Licensee was encouraged to visit the Department’s website at http://ccld.ca.gov/ for information regarding child care updates, forms, regulations and legislation pertaining to Family Child Care Homes.

To improve the quality and value of the new inspection process, a survey will be sent to the e-mail 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 e-mail 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.

An exit interview was conducted and report was reviewed with the licensee, Caroline Leyva. A copy of the report was provided to the licensee. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Chayntel Hunter	TELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Tiffanie Diep	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/25/2023 05:00 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 SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: LEYVA, CAROLINE	FACILITY NUMBER: 393622862
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as there was Lysol located on a dining table and Tylenol and hydrogen peroxide in a storage closet accessible to children in care which posed an immediate health, safety, or personal rights risk to children in care.
	POC Due Date: 01/26/2023
	Plan of Correction
1 2 3 4	Licensee removed the Lysol from the dining table and placed it in a latched cabinet inaccessible to children and placed a doorknob cover to ensure inaccessibility to the storage closet containing Tylenol and hydrogen peroxide. Deficiency was cleared during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Chayntel Hunter	TELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Tiffanie Diep	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC809 (FAS) - (06/04)

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