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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700346
Report Date: 04/21/2023
Date Signed: 04/21/2023 06:48:10 PM

Document Has Been Signed on 04/21/2023 06:48 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:FALCON, YSAMELFACILITY NUMBER:
015700346
ADMINISTRATOR:FALCON, YSAMELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 378-4829
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 15DATE:
04/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ysamel FalconTIME COMPLETED:
06:45 PM
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On April 21st,, 2023 at approximately 1:15pm, Licensing Program Analyst (LPA) April Wright met with licensee Ysamel Falcon for an Unannounced Required 1 Year Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee assistant. Present during inspection were fifteen (15) children and fingerprint cleared assistant Angelica Llamas de Flores. The licensee is out of ratio today. Hours of operation are 7:00am - 6:00pm Monday through Friday.

LPA toured the facility to conduct a health and safety inspection. The two story home was neat and orderly, with heating and ventilation for safety and comfort of children in care. The isolation area is the living room which is a section away from other children in care.

On limit areas include: Day care areas that are downstairs and consisted of Dining /office room, bathroom #1 in living room, backyard.
Off-limits areas include: Entire second level, all stairways, all closets, living room, kitchen and bathroom #2, garage, storage shed in the backyard. Per Licensee, day care children will be entering/exiting through the backyard door to get into the day care room.

The off limits are and will be made inaccessible by closed and/or locked doors and visual supervision. There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today’s inspection. LPA did not observe any hazardous materials or toxins accessible to children during today's inspection. There are age appropriate toys that appear to be safe and in good condition.

The home has a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detector, fully stock First Aid Kit. and telephone. There is a fireplace in the living room that is blocked and inaccessible to children. Per licensee there are no firearms in the home. The licensee is in compliance with the immunization laws which pertains to all childcare providers.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: FALCON, YSAMEL
FACILITY NUMBER: 015700346
VISIT DATE: 04/21/2023
NARRATIVE
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LPA requested and reviewed the files of fifteen (15) children in care. The children's files contained, Parents rights, medical consent forms and identification and emergency contacts. C1, C2, C3 and C7 did not have LIC 627 forms in the the child's file. The facility roster was review and copies were obtained. The licensee conducts fire and disaster drills twice a year and the last was conducted on 3/3/2023. The licensee has a current CPR/First aid certificate which expires on 2/2024 and Mandated Reporter training certificates expire on 12/11/2023. All required forms are posted and visible for public review.

Incidental Medical Services (IMS) policy was discussed. NO IMS PROVIDED AT THIS FACILITY. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

California Law requires Child Care Centers 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 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Roster of the children must be properly maintained, and fire/disaster drill every six months must be documented. The licensee is reminded any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

LPA discussed the Safe sleep regulations with licensee and discussed Child Care Licensing Safe Sleep webpage 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.


See LIC809C for continuance.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: FALCON, YSAMEL
FACILITY NUMBER: 015700346
VISIT DATE: 04/21/2023
NARRATIVE
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Licensee was reminded that all adults 18 and over, 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 childcare center. 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.

Licensee was encouraged to frequently visit our website at ccld.ca.gov for licensing regulations and updates. The licensee is reminded any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.


The following deficiencies were observed during today's inspection: (See LIC809D)
  • Type A - LPA observed 3 children in infant seats/bouncers/rockers while sleeping
  • Type A - Licensee was out of ratio - 15 children present (2 infant /13 preschool age children)
  • Type B - Assistant does not have current Mandated Reporter Training
  • Type B - Consent for Medical Treatment LIC627 in not present in C1, C2, C3, C7 file
  • Type B - Immunization's are not present in C2, C3 file
  • Type B - Infant Sleep Plan LIC 9227 not present in C7, C14 file
  • Type B - Sleep log not present in C7, C14 file
  • Technical Violation - LPA observed the children's roster is not updated/current


A notice of site visit was given and must remain posted 30 days. Exit interview conducted and report was reviewed with Ysamel Falcon.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 04/21/2023 06:48 PM - It Cannot Be Edited


Created By: April Wright On 04/21/2023 at 05:51 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: FALCON, YSAMEL
FACILITY NUMBER: 015700346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(h)
Infant Safe Sleep
Car seats shall only be used for transportation purposes and shall not be used for sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in LPA observed 3 children in infant seats/bouncers while sleeping, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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LPA advised Licesee to watch Safe Sleep video on ccld.ca.gov website and review regualtions on the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep.
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in fifteen (15) children were present at time of inspection, two (2) infants and thirteen (13) preschool age children, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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LICENSEE WAS OUT OF RATIO. Licensee immediately reduced numbers to within capacity specified on license. LPA to revisit to ensure Licensee is remaining within ratio. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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:Chandra Charles
LICENSING EVALUATOR NAME:April Wright
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 04/21/2023 06:48 PM - It Cannot Be Edited


Created By: April Wright On 04/21/2023 at 05:51 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: FALCON, YSAMEL
FACILITY NUMBER: 015700346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 Daycare assistant Angelica Llamas De Flores has not completd Mandated Reporter training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Assistant Angelica Llamas De Flores will complete Mandated Reporter training by the due date above and submit completion certificate to LPA.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

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 poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee will update child forms and place in file by the 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:Chandra Charles
LICENSING EVALUATOR NAME:April Wright
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 04/21/2023 06:48 PM - It Cannot Be Edited


Created By: April Wright On 04/21/2023 at 05:51 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: FALCON, YSAMEL
FACILITY NUMBER: 015700346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

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 four children (C1, C2, C3 and C7) did not have LIC 627 Consent for Medical Treatment forms in their file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee will update child file witj LIC 627 and place in file by the due date
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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 two (2) infants did not have Infant Sleep Plans LIC9227 in their files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee will have parents complete LIC9227 forms by the due date listed above and complete forms for incoming children going forward.
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:Chandra Charles
LICENSING EVALUATOR NAME:April Wright
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 04/21/2023 06:48 PM - It Cannot Be Edited


Created By: April Wright On 04/21/2023 at 05:51 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: FALCON, YSAMEL
FACILITY NUMBER: 015700346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

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 which two (2) infants did not have current sleep logs, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee will begin sleep log documentation for two (2) infants in care on 4/24/2023
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:Chandra Charles
LICENSING EVALUATOR NAME:April Wright
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
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