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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421181
Report Date: 07/01/2022
Date Signed: 07/01/2022 02:23:21 PM


Document Has Been Signed on 07/01/2022 02:23 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:ROCA, MAYRAFACILITY NUMBER:
013421181
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: DATE:
07/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Mayra RocaTIME COMPLETED:
02:25 PM
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On July 1, 2022 Licensing program Analyst (LPA) Indira Loza arrived at the facility to conduct an annual random inspection. Present for the inspection were the Licensee, one infant and three preschool aged children. The home was inspected to conduct a Health and Safety check. Operating hours are Monday through Friday 8:00am to 5:00pm.

The home is a two story home. The home consists of a living room, kitchen, 3 bedrooms, 1 bathroom, a basement converted into a bedroom, driveway and an inaccessible garage on the side of the house. There is a bedroom on each level of the home. The bedroom on the main floor is a play/nap room. There is a fully charged 2A10BC fire extinguisher and a working smoke alarm. The On Limit areas are the driveway, living room, dining room, bathroom, and the bedroom to the right of the dining room. The Off Limit areas are the basement, the inaccessible garage and upstairs bedroom, and the kitchen, which the children only walk through to access the bathroom. The Isolation Area is the play/nap room on the main floor. The outdoor play area is the driveway. The Licensee states that there are no firearms in the home.

The Licensee has a current pediatric CPR and First Aid certificate which expire on March 2024. The Licensee provides food and snacks to the children. There are no children in care who receive Incidental Medical Services. LPA Loza reviewed the children's files and obtained a copy of the children's roster.

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone or fax. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.

Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months
*****************************************Report Continues on LIC 809-C*******************************************
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ROCA, MAYRA
FACILITY NUMBER: 013421181
VISIT DATE: 07/01/2022
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and documented. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02 CCP. 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.

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 athttps://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
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.

Licensee was issued two Type B citations. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Mayra Roca.

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 07/01/2022 02:23 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: ROCA, MAYRA
FACILITY NUMBER: 013421181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

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 as the carbon monoxide detector did not have batteries and was not functioning which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will email a copy of a receipt for purchase of new batteries, as well as a picture of the new batteries inserted into the carbon monoxide detector.
Type B
Section Cited
CCR
102417(g)(9)(A)
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.

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 as there was not a current disaster drill completed withing the past six months which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will conduct a disaster drill with the children and email the department an updated copy of the disaster drill log.

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: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
LIC809 (FAS) - (06/04)
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