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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070209044
Report Date: 11/15/2018
Date Signed: 04/15/2022 03:30:32 PM

Document Has Been Signed on 04/15/2022 03:30 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:CLARK, GUADALUPE & JUDSONFACILITY NUMBER:
070209044
ADMINISTRATOR:CLARK, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 937-6152
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 12TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
11/15/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Guadalupe ClarkTIME COMPLETED:
11:05 AM
NARRATIVE
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3 Licensing Program Analyst, (LPA), R. Hollie, met with Licensee for the purpose of a Random Health and Safety Inspection. Present at the start of the visit, was Mr. Clark, who left for work shortly after the start of the visit, the licensee's assistant, Teresa Ramirez, the licensee and three day care children. The OFF LIMITS of the home is th e licensee's son's bedroom located near the kitchen area. Children have access to the rest of the home.

Per the Licensee there are no bodies of water on the premises nor are there guns on the premises. Poisons, detergents, cleaning compounds and medications are inaccessible to children. There is a working smoke detector and a charged fire extinguisher (2a10bc) as well as a carbon monoxide detector. The home is free of stairs, however, there is a step down family room area. The home has toys, play equipment and materials for children. The licensee understands that children are to be supervised at all times. The licensee is aware that children are not to be locked in cars or other areas of the home.
PLEASE SEE NEXT PAGE FOR CONTINUED REPORT
SUPERVISORS NAME: Anika Evans
LICENSING EVALUATOR NAME: Ronda Hollie
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2018
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044
VISIT DATE: 11/15/2018
NARRATIVE
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The licensee was informed that when or if she is temporarily absent from the home, a fingerprint cleared adult, who holds a current CPR/FA must be present in her absence. The licensee shall always maintain the capacity specified on the license. The home appears to have healthful, safe and comfortable accommodations, furnishings and equipment for children. There is a current roster of the children. The home conducts fire and disaster drills, per the licensee. The licensee documents immunization's for children as required.

The licensee provides parents with a Notification of Parents Rights.
The Licensee understands that unannounced visits by CCL Employees, provided ID is shown and in the course of business, may enter and inspect areas of her home where she provides personal care and services to children.
The licensee understands that upon notice of the Department to remove an individual from the home, pursuant to H&S Code 1596.871(c)(2) or to exclude an individual from the home, pursuant to H&SCode 1596.8897, the licensee immediately removes the individual and prevents them from returning to the home or having contact with children in care. The licensee must ensure that all adults working, residing or volunteering in a licensed home, must obtain a criminal record review (fingerprint clearance) prior to being in the presence of children.
PLEASE SEE NEXT PAGE FOR CONTINUED REPORT
SUPERVISORS NAME: Anika Evans
LICENSING EVALUATOR NAME: Ronda Hollie
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2018
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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: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044
VISIT DATE: 11/15/2018
NARRATIVE
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LPA discussed and advised licensee to check in with parent or guardians if children fail to arrive to the day care as scheduled. LPA encouraged the Licensee to review our website at the above address at CCLD.CA.GOV to stay up to date and informed on Laws and Title 22 Regulations as it relates to her day care business, Particularly, the Provider Information Notices, known as PINS.

THE LICENSEE WAS PROVIDED A COPY OF THEIR APPEAL RIGHTS (LIC 9058 12/15) AND THEIR SIGNATURE ON THIS FORM ACKNOWLEDGES RECEIPT OF THESE RIGHTS. LPA POSTED THE REQUIRED POSTINGS FOR PUBLIC VIEWING. The licensee as informed that if the facility receives a deficiency, the facility must make the corrections by the date on the report (809-d) or the facility will receive a penalty of $100 per day until the deficiency is corrected. LPA discussed at length and provided documentation as it related to safe sleep for infants. The outside remains fenced and the upper yard is off limits. Swing-set is anchored. LPA advised s-hooks be tightened prior to allow children to play on swings.

PLEASE SEE 809-D FOR TYPE B DEFICIENCY.

LPA was informed at 9:25am that immunization and mandated reporter training has not bee completed.

SUPERVISORS NAME: Anika Evans
LICENSING EVALUATOR NAME: Ronda Hollie
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2018
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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: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044
VISIT DATE: 11/15/2018
NARRATIVE
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The licensee and her assistant have current CPR/FA which expires in 10-2020. Children's records were reviewed during this visit.

Incidental Medical Services (IMS) policy was discussed. 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. The licensee is not currently caring for any children that require IMS services today.

LPA DISCUSSED WITH LICENSEE THAT AS OF SEPTEMBER 1, 2016, ANY PERSON(S) EMPLOYED OR VOLUNTEERING AT A FAMILY DAY CARE HOME SHALL BE IMMUNIZED AGAINST INFLUENZA, PERTUSSIS AND MEASLES OR MUST QUALIFY FOR AN EXEMPTION. LPA INFORMED THE LICENSEE IF PERSON’S DO NOT WISH TO OBTAIN AN INFLUENZA VACCINE, A WRITTEN STATEMENT DECLINING THE FLU SHOT MUST BE AVAILABLE DURING THE VISIT. SEE NEXT PAGE FOR CONTINUED REPORT

SUPERVISORS NAME: Anika Evans
LICENSING EVALUATOR NAME: Ronda Hollie
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2018
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Document Has Been Signed on 04/15/2022 03:30 PM - It Cannot Be Edited


Created By: Ronda Hollie On 11/15/2018 at 09:47 AM
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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CLARK, GUADALUPE & JUDSON
FACILITY NUMBER: 070209044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2018
Section Cited
HSC
1597.622

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HEALTH & SAFETY 1597.622 A person may not be employed at a Family Day Care unless he or she has been immunized against, pertussis and measles or qualifies for an exemption. This requirement is not being met
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No later than December 14, 2018, the licensee will submit a copy of both her and her assistant's measles and pertussis vaccination and influenza or a letter declining the flu shot.
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The licensee nor her assistant, Ms. Ramirez, have verification of their immunization of pertussis or meales as required. This poses a potential risk to the health and safety of children in care.
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Type B
12/14/2018
Section Cited
HSC1596.8662b1

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HEALTH AND SAFETY 596.8662b1
A Licensed child care provider as well as their employee;s shall complete the mandated reporter training and renew as required. This requirement is not being met.
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No later than December 14, 2018, the licensee and her assistant must complete the training and send a copy of the certificate to LPA.
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The licensee nor her assistant have received Mandated Reporter Training as required. This poses a potential risk to the health and safety of 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:Anika Evans
LICENSING EVALUATOR NAME:Ronda Hollie
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2018


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