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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192001526
Report Date: 03/23/2023
Date Signed: 03/23/2023 10:59:15 AM

Document Has Been Signed on 03/23/2023 10:59 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:CERVANTES FAMILY CHILD CAREFACILITY NUMBER:
192001526
ADMINISTRATOR:CERVANTES, SILVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 266-7233
CITY:LOS ANGELESSTATE: CAZIP CODE:
90022
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
03/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Silvia Cervantes, LicenseeTIME COMPLETED:
11:15 AM
NARRATIVE
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Inspection conducted in Spanish

On March 23, 202, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced case management inspection for the above facility. A COVID-19 risk assessment was conducted prior to entering the facility. LPA met with licensee, Silvia Cervantes who guided LPA on a tour of the facility. LPA did not observe any children in care.

The purpose of this inspection is to issue deficiencies to the licensee for not having a current facility roster (corrected on 03/22/2023), not reporting unusual incident reports to the department within the required time frame, cleaning compounds/solutions being accessible to children in care and for incomplete children files. It was observed on 03/22/2023 that Child #1( C1) missing LIC282, LIC627 and LIC995A, Child #2 (C2) missing immunization, Child #3 (C3) missing LIC282, LIC700, LIC627, LIC995A, LIC9227, Immunizations and Infant Sleeping Log, Child #4 (C4) missing LIC282, LIC627 and LIC995A (See LIC811).

The facility was not found to be in compliance with Title 22 Regulations and is being cited under California Code Regulations Title 22, see LIC809D.

An exit interview was conducted and a copy of this report was provided to the licensee along with Notice of Site Visit and Appeal Rights.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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 03/23/2023 10:59 AM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 03/23/2023 at 10:01 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CERVANTES FAMILY CHILD CARE
FACILITY NUMBER: 192001526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited
CCR
102418(a)

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Immunizations: Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. This requirement was not as evidence by: Based on record review C2 and C3 do not have
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Licensee will speak with C3 parent to bring a copy of the immunization by POC date (03/31/2023).
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immunizations on record. This poses a potential health and safety risk to children in care.
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Type B
03/31/2023
Section Cited
CCR102419(d)(1)

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Admission Procedures and Parental...:At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parents’ Rights, LIC 995A... The licensee shall request the child's parent... to sign and
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Licensee will ensure that children enrolled and newly enrolled children will have the LIC955A completed and in their file.
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date the bottom portion of the notice form LIC 995A (8/06), ... has received and read the LIC 995A. This requirement was not met as evidence by: Based on observation C1, C2 and C3 do not have a signed copy of LIC995A in their file. This poses a potential health and safety risk to 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:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/23/2023 10:59 AM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 03/23/2023 at 10:10 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CERVANTES FAMILY CHILD CARE
FACILITY NUMBER: 192001526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited
CCR
102417(g)(7)

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Operation of a Family Child Care Home: The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: An emergency information card shall be maintained for each child and shall include the child's full name... This requirement
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Licensee will have C3 mother complete the form by POC date (03/31/2023)
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was not met as evidence by: Based on record review C3 does not have a complete LIC700 in their file. C1, C3 and C4 did not have a signed LIC627 on file. This poses a potential health and safety risk for children in care.
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Type B
03/31/2023
Section Cited
CCR102417(m)(3)

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Operation of Famly Child Care Home: The licensee or registrant shall maintain one of the following: A file of affidavits signed by each parent with a child enrolled in the home... This requirement was not met as evidence by: Based on record review C1, C3 and C4 do not have a signed LIC282 on file
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Licensee will ensure that enrolled children and newly enrolled chilren have the form signed by their parent to place in the file.
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This poses a potential health and safety risk to 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:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/23/2023 10:59 AM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 03/23/2023 at 10:20 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CERVANTES FAMILY CHILD CARE
FACILITY NUMBER: 192001526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2023
Section Cited
CCR
102425(j)(1)

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Infant Safe Sleep: The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes. This requirement was not met as evidence by: Based on record review C3 does not have any
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Licensee will start documenting C3 every 25 minutes starting 03/23/2023.
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documentation for napping/sleeping. Per licensee, she was unaware of regulation. This poses a potential health and safety risk to children in care.
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Type B
03/23/2023
Section Cited
CCR102417(g)(8)

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Operation of a Family Child Care Home: Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met as evidence by: Based on record review the licensee did not have a current facility roster on 03/22/23
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Licensee has completed the roster on 03/22/2023.
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Licensee completed the roster on 03/22/2023. This posed a potential health and safety risk to 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:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/23/2023 10:59 AM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 03/23/2023 at 10:31 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CERVANTES FAMILY CHILD CARE
FACILITY NUMBER: 192001526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2023
Section Cited
CCR
102417(g)(4)

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Operations of a Family Child Care Home: The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: Poisons, detergents, cleaning compounds... which could pose a danger if readily available to children shall be stored
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Licensee will ensure that all cleaning solutions and cleaning compounds will be made inaccessible to children in care by placing safety latches.
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where they are inaccessible to children. This requirement was not met as evidence by: Based on observation, LPA observed cleaning solutions under the restroom sink without safety lactes and a bottle of Clorox wipes accessible. This poses a potential health and safety risk to children in care.
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Type B
03/24/2023
Section Cited
CCR102416.2(a)

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Reporting Requirements: The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). This requirement was not met as evidence by: Based on interview with the licensee, she
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Licensee will start reporting all unusual incident reports to the department within the required time frame.
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did not report incidents that occurred over a year ago and did not report an incident that occurrred earlier this week to the department. This poses a potential health and safety risk to 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:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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