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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153911457
Report Date: 03/13/2023
Date Signed: 03/13/2023 01:15:15 PM

Document Has Been Signed on 03/13/2023 01:15 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:SEPULVEDA, JENNIFER FAMILY CHILD CAREFACILITY NUMBER:
153911457
ADMINISTRATOR:SEPULVEDA, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 608-3447
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
03/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jennifer SepulvedaTIME COMPLETED:
01:30 PM
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On 3/13/2023, Licensing Program Analyst (LPA) Theresa Marquez conducted an unannounced Required 1 year inspection and met with Licensee, Jennifer Sepulveda. Assistant Vanessa Sepulveda was also present. A tour of the home was conducted, and a census was taken. Current facility sketch reviewed, and Licensee confirmed the living room, dining/kitchen area, the day care room, and hall bathroom are used for providing care and are accessible to day care children. All other rooms are off-limits and are made inaccessible by use of handle locks. Hours of operation are Monday through Friday 7:00 AM to 4:30 PM.

Medications and other hazardous items were inaccessible to children. The fire extinguisher, smoke detectors, and carbon monoxide detector met Community Care Licensing (CCL) regulations. Heating/cooling and ventilation was sufficient for safety and comfort. There were no stairs in the home. Safe toys and play equipment were observed. Staff-child ratios were maintained.

There are currently no infants in care. LPA discussed the safe sleep regulations with licensee Sepulveda 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 as an additional resource. LPA also informed licensee Sepulveda 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.

The outdoor play area in the backyard is fenced. Licensee has 4 dogs that are accessible to children. Licensee is aware of child safety around pets and accepts responsibility for any action taken by pets. Swimming pool was fenced per regulation with a gate that is self-latching, self-closing, and opens away from the swimming pool. No windows or doors have direct access to the swimming pool area. There are no firearms on the property. Continued on LIC809-C
SUPERVISORS NAME: Luisa Gavoutian
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: SEPULVEDA, JENNIFER FAMILY CHILD CARE
FACILITY NUMBER: 153911457
VISIT DATE: 03/13/2023
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A sample of children’s records contained all emergency information specified by regulation. A review of records indicated Licensee and her assistant have proof of required immunization (Pertussis/Measles/Influenza) and/or written declaration declining flu shot. Licensee's Mandated Reporter Training was completed on 1/4/2023. Licensee's pediatric CPR and First Aid expires on 2/18/2024.

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

Licensee Sepulveda 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, 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.
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 deficiency was found: Licensee is no documenting children's immunization records on form PM 286. (see page LIC809-D):

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/process.

An exit interview was conducted and report was reviewed with the Jennifer Sepulveda. A copy of the evaluation report, Appeal Rights and the Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Luisa Gavoutian
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/13/2023 01:15 PM - It Cannot Be Edited


Created By: Theresa Marquez On 03/13/2023 at 12:16 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: SEPULVEDA, JENNIFER FAMILY CHILD CARE
FACILITY NUMBER: 153911457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
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. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

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. Licensee is not documenting children's immunizations on form PM 286. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2023
Plan of Correction
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Licensee stated she will document the children's immunizations on form PM 286. Licensee is to submit a written statement to the Fresno South licensing office as proof of correction by March 29, 2023. LPA Marquez provided a blank form PM 286 to licensee Sepulveda today.
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:Luisa Gavoutian
LICENSING EVALUATOR NAME:Theresa Marquez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023


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