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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197413650
Report Date: 06/17/2022
Date Signed: 06/17/2022 02:59:26 PM

Document Has Been Signed on 06/17/2022 02:59 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
197413650
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Ana Perez, LicenseeTIME COMPLETED:
03:20 PM
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Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 6/17/22 at 12:45 PM. LPA met with Ana Perez, Licensee who guided analysts on a tour of the facility. There were two school age children present when LPA arrived. Assistant and one more school age child arrived during inspection. Facility capacity is in compliance for a small Family Child Care Home.

This is a Two-story home which consists of four bedrooms, two bathrooms, kitchen/eating area, two living rooms, a foyer, front yard and backyard (fenced). Main care is provided in the two living rooms at the front of the house. Per Licensee, areas off limits to children and parents include: two bedroom and bathroom upstairs and two bedrooms downstairs (locked).

Hours of operation are Monday-Friday, 6AM-9PM. Food is provided by facility. Licensee was reminded if children bring food from home it must be labeled with the child’s name and properly stored or refrigerated.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:

LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on 6/13/22. All documents observed on the parent board in the foyer.

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SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197413650
VISIT DATE: 06/17/2022
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Smoke and carbon monoxide detectors located in the living room were tested and are operable. Fire extinguisher indicated fully charged and was serviced within the year, 2/2022. The home maintains telephone service via landline and cell phone. There are toys and other age appropriate material available for children. Wall heater was observed down the hallway near the off limits bedroom. Per licensee, the heater is inoperable. LPA observed that detergents and cleaning compounds are stored in the kitchen with a child lock. Licensee states that there are no poisons or medication stored in the home. LPA reminded licensee that poisons must be stored in a locked area not just out of reach. Facility has ceiling fans for ventilation. Isolation area for sick children waiting to be picked up is in the foyer or one of the living rooms, away from the other children. Per licensee there are no firearms or weapons stored in the home.

The children use the bathroom located down the hallway toward the back of the house. Bathroom was observed to be clean and free of hazards.

Infant Care: Currently licensee does not care for infants. LPA informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP.

Currently, children are using the backyard yard for outdoor play. The outdoor play area was observed to be fenced. LPA did not observe any objects that could be hazardous to children in care. There is a makeshift storage area to the left of the backyard surrounded with black tarp. There are no pools or spas, or other bodies of water.



Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, and LIC 995A Notification of Parents’ Rights. Files complete.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508- Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. Files complete.

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SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197413650
VISIT DATE: 06/17/2022
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During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

LPA observed that facility is implementing COVID-19 precautions and procedures.

Incidental Medical Services (IMS):
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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Based on LPA observations no deficiencies will be cited today 6/17/22.

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.

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.

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 as an

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SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197413650
VISIT DATE: 06/17/2022
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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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Facility Representative Ana Perez.

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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