<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407708
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:41:04 PM

Document Has Been Signed on 07/06/2023 04:41 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:LOPEZ, GUADALUPEFACILITY NUMBER:
073407708
ADMINISTRATOR:LOPEZ, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 516-7645
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
07/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Guadalupe LopezTIME COMPLETED:
04:50 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 July 6, 2023 at 1:11 Licensing Program Analyst (LPA) Indira Loza & a Contra Costa County CPS worker met with Licensee Guadalupe Lopez for an unannounced case management visit. Present for the inspection were one infant, one preschool age child, and two fingerprint cleared adults.

The Licensee and foster children were interviewed during today's visit. LPA observed an infant sleeping in a playpen with a pillow, a blanket, and a play mat vertically inside the crib's wall used to create a solid wall. This violates California Code Regulations (CCR) 102425 which is a Type A deficiency.

See LIC809-D for citation.

The Licensee must provide a copy of the LIC9224 to all currently enrolled parents, and newly enrolled parents for the next 12 months. A copy of the signed report must be placed and kept in the children's file.

Report and Appeal Rights reviewed an provided to Licensee Guadalupe Lopez.
A notice of Site visit was given to the Licensee and must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/06/2023 04:41 PM - It Cannot Be Edited


Created By: Indira Loza On 07/06/2023 at 04:09 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: LOPEZ, GUADALUPE
FACILITY NUMBER: 073407708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2023
Section Cited
CCR
102425(b)

1
2
3
4
5
6
7
Infant Safe Sleep - (b) Cribs or play yards shall be free from all loose articles and objects. This requirement was not met as evidenced by: Based on observation, the LPA saw a
1
2
3
4
5
6
7
Licensee shall review the Infant Safe Sleep regulation, write a summary of the regulation, and list what was learned. The Licensee shall send this no later than 7//23.
8
9
10
11
12
13
14
Based on observation there was a blanket, pillow, and a play mat inside the pack'n'play, wedged vertically between the net of the pack'n'play and the matress to create a solid wall. This is an immediate risk to the health and safety of the children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2