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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423297
Report Date: 07/12/2021
Date Signed: 07/12/2021 04:58:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/12/2021 04:58 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:VELEZ, MARIAFACILITY NUMBER:
013423297
ADMINISTRATOR:VELEZ, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 776-3713
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria ValezTIME COMPLETED:
04:58 PM
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On 7/12/2021 at 3:00pm Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Maria Valez for an unannounced annual inspection. Present during the inspection was the Licensee and her five (5) foster daughters. There were two (2) infants and four (4) preschool children present during the inspection. Licensee lives in the home with her five (5) foster daughters. The Licensee’s home was toured for a health and safety inspection. The operating hours are 7:00am – 6:00pm Monday – Friday.

ON LIMITS AREA: Living Room, Kitchen, Hallway Bathroom, Detached Converted Garage, Enclosed Patio, Front Yard and Backyard


OFF LIMITS AREA: All three (3) bedrooms, Pool area of the Backyard
ISOLATION AREA: Living Room

The facility is a single-story home rented by the Licensee. The inside of the home is observed to be neat, clean with ample age appropriate materials for the children that are safe and clean. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there no firearms and no pets in the facility.

The home has one (1) fully charged 3A40BC fire extinguisher in the kitchen and one (1) 3A40BC fire extinguisher located in the converted garage. There is one (1) working smoke detector in the hallway and one in the converted garage. There is a working carbon monoxide detector in hallway. The pull-down fire alarm is located in the living room. The home is equipped with many windows for proper ventilation and two (2) wall heaters in the hallway that have been covered and made inaccessible to the children in care with custom built fences that are securely attached to the wall.

Cont on 809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: VELEZ, MARIA
FACILITY NUMBER: 013423297
VISIT DATE: 07/12/2021
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There is a newly finished in ground pool in the back portion of the back yard. It is surrounded by a 5ft fence that makes it inaccessible to the children in care. Licensee must install a proper self-closing door that swings away from the pool and a proper self-latching device located no more than six inches from the top of the gate.

At 3:53pm LPA obtained the facility roster and the children’s files. The files and the facility roster were complete. The Licensee’s Health and Safety training plus Lead Poisoning training has been completed and CPR and First Aid training is complete with an expiration date of 7/10/2022. Licensee’s fire and disaster drill log is complete with the last drill logged 6/21/2021. Licensee’s Mandated Reporter training is current and expires on 3/10/2023. All required forms are posted and visible for public view on the living room walls.

Licensee was reminded that California Law requires licensees 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, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.



Incidental Medical Services (IMS) policy was discussed as well. Licensee was reminded that when any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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 is reminded that ALL Licensees, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3,000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter.
Cont on 809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: VELEZ, MARIA
FACILITY NUMBER: 013423297
VISIT DATE: 07/12/2021
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Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six months 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.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates.

This report was read and given to the Licensee for a signature. There is one (1) Type B deficiency being cited today. This report shall remain on file for 3 years. Appeal Rights were provided and exit interview conducted. A Notice of Site visit was given and must be posted for 30 days.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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Document Has Been Signed on 07/12/2021 04:58 PM - It Cannot Be Edited


Created By: Morgan Pringle On 07/12/2021 at 04:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: VELEZ, MARIA
FACILITY NUMBER: 013423297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2021
Section Cited
CCR
102417(g)(5)(A)

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(A) The home shall be free from defects or conditions which might endanger a child…(5) All licensees shall ensure the inaccessibility of pools…gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate…
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Starting 7/13/2021 the backyard of the facility will remain off limits to all children in care under the licensee's supervision until the gate and lock is properly added to the pool fence. Licensee will inform LPA of completed deficiencies in the form of pictures.
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This requirement was not met as evidenced by: Pool fence is not equipped with a proper gate or lock. This poses a potential health and safety risk to the children in care.
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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:Jason Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2021


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