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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103904345
Report Date: 03/28/2023
Date Signed: 03/28/2023 11:50:57 AM

Document Has Been Signed on 03/28/2023 11:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:HERNANDEZ, STACEY FAMILY CHILD CAREFACILITY NUMBER:
103904345
ADMINISTRATOR:HERNANDEZ, STACEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 252-3441
CITY:FRESNOSTATE: CAZIP CODE:
93737
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
03/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Stacey Hernandez - LicenseeTIME COMPLETED:
12:15 PM
NARRATIVE
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On 3/28/23 Licensing Program Analyst (LPA) Joseph Pacheco, conducted an unannounced Annual Required Inspection and was met by Licensee, Stacey Hernandez. Also present was Staff #1 (S1). Days and hours of operation are Monday – Friday, 7:30am – 5:00pm.
LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed. Licensee confirmed that the nap room, play room and bathroom adjacent to the play room are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of child safety gates or locks. There are no firearms or ammunition on the premises. A poison that was inaccessible to children but not locked was observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. The pellet stove located in the living room is made inaccessible by a locked door and will not be in use during daycare hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed with licensee the contact phone number is (559) 252-3441.
There are currently two infants in care. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes but has not been documenting those checks. Licensee understands she is to document any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
CONTINUED ON 809-C
SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2023
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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Document Has Been Signed on 03/28/2023 11:50 AM - It Cannot Be Edited


Created By: Joseph Pacheco On 03/28/2023 at 10:52 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: HERNANDEZ, STACEY FAMILY CHILD CARE
FACILITY NUMBER: 103904345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation. During an inspection of the outdoor play area, LPA observed a big wheel toy that was missing a pedal and the second pedal was broken. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2023
Plan of Correction
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Licensee removed the big wheel do an area of the backyard which is off-limits to children in care. Deficiency cleared.
Type B
Section Cited
CCR
102417(g)(4)(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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation. LPA observed Raid Ant Killer on the top of Licensee's refrigerator which was inaccessible to children but not locked. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2023
Plan of Correction
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Licensee removed the poison from the top of the refrigerator to a locked storage area. Deficiency cleared.
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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023


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Document Has Been Signed on 03/28/2023 11:50 AM - It Cannot Be Edited


Created By: Joseph Pacheco On 03/28/2023 at 10:52 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: HERNANDEZ, STACEY FAMILY CHILD CARE
FACILITY NUMBER: 103904345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023

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 observation. During review of facility records, LPA observed that Licensee and Staff #1 do not have documentation of a current AB 1207 Mandated Reporter certificate. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2023
Plan of Correction
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Licensee stated she and Staff #1 will complete the required Mandated Reporter training at www.mandatedreporterca.com and provide copy of a current certificate to Community Care Licensing by 4/18/23.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation. During review of facility records, LPA observed that Licensee and Staff #1 do not have documentation of a current Pediatric CPR card. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2023
Plan of Correction
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Licensee stated she will enroll in an approved CPR course and provide LPA with proof of enrollment by 4/18/23.
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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023


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Document Has Been Signed on 03/28/2023 11:50 AM - It Cannot Be Edited


Created By: Joseph Pacheco On 03/28/2023 at 11:07 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: HERNANDEZ, STACEY FAMILY CHILD CARE
FACILITY NUMBER: 103904345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)
Application for Initial License. (b) The applicant shall provide all of the following information at the time of submission of the application: (9) Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement was not met as evidenced by observation. During review of Personnel Records, LPA observed that Staff #1 does not have documentation of a tuberculosis screening. This is a potential risk to the health, safety, or personal rights of children in care.
POC Due Date: 04/18/2023
Plan of Correction
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Licensee stated she will have Staff #1 obtain documentation of a current health screening and provide documentation to Community Care Licensing by
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023


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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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: HERNANDEZ, STACEY FAMILY CHILD CARE
FACILITY NUMBER: 103904345
VISIT DATE: 03/28/2023
NARRATIVE
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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.
Per licensee, she ensures that children in care are always supervised and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced. Capacity as specified on the license is being maintained.
LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee and S1 do not have a current AB 1207 Mandated Reporter certificate or a current pediatric CPR card. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles. S1’s file did not contain documentation of a current tuberculosis clearance.
All adults who reside or work in the home have a criminal record clearance or exemption. 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. Per licensee, there are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D). Licensee was provided a copy of appeal rights.
CONTINUED ON 809-C
SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
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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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: HERNANDEZ, STACEY FAMILY CHILD CARE
FACILITY NUMBER: 103904345
VISIT DATE: 03/28/2023
NARRATIVE
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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/inspection-process.

Exit interview conducted and report was reviewed with the Licensee, Stacey Hernandez.

This report shall be made available to the public upon request. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
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