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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419064
Report Date: 03/15/2024
Date Signed: 03/19/2024 08:23:43 AM


Document Has Been Signed on 03/19/2024 08:23 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:CUA VILLALTA FAMILY CHILD CAREFACILITY NUMBER:
197419064
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 632-1169
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY:14CENSUS: 7DATE:
03/15/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:
LICENSEE
CUA VILLALTA, ELENA
TIME COMPLETED:
04:45 PM
NARRATIVE
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On 3/15/24 at 8:15am Licensing Program Analysts (LPA), Jeanine Lipsey conducted an unannounced Required Annual Inspection and was met by Licensee, Elena Cua Villalta. LPA observed 7 children in care today. Days and hours of operation are Monday through Friday 7:30ma to 6pm. Signed Affidavit Regarding Liability Insurance are in the children files.

LPA Lipsey observed the following required postings: License, LIC 610A Emergency Disaster Plan, PUB 394 Notification of Parents’ Rights Poster, and LIC 9148 Earthquake Preparedness Checklist. LPA advised all LIC9213 Notice of Site Visits shall be posted for 30 days after each site visit. LPA advised, any licensing report documenting a Type A citation must be posted for 30 days. LPA advised a disaster drill log shall be posted with disaster drills completed at lease every six months.

LPA toured the playrooms and the outside area. This is a one story, two bedrooms, three bathrooms home with living room, kitchen, 2 playrooms and detached garage. Both playrooms are used for childcare.

The areas that are accessible to children: are the children’s playrooms, 1 bathroom, and the backyard for outdoor activities.

LPA did not observe any poisons present during the inspection. Detergents, cleaning compounds, medication and other hazardous item were made inaccessible to children. Per applicant, there are no firearms, or weapons on the premises. LPA did not observe any bodies of water on the premises. LPA observed the home to be free from defects or conditions which may endanger the children. Safety gate was installed for the off-limit area.

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SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Jeanine LipseyTELEPHONE: (424) 301-3077
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
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 9


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CUA VILLALTA FAMILY CHILD CARE
FACILITY NUMBER: 197419064
VISIT DATE: 03/15/2024
NARRATIVE
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LPA observed fully stocked first aid kit. LPA Lipsey observed a working carbon monoxide detector in the home, LPA was able to hear a successful test. Smoke detectors are located in the play area. Fire extinguisher 2A10BC was observed, located on the wall of the playroom and was last serviced on 12/13/22. Electrical outlets were observed to be inaccessible to children in care with the use of plug covers. The home was observed to be clean and orderly with heating and ventilation. LPA observed safe toys, play equipment, and materials. LPA verified the home has a working telephone service; phone number is (818) 632-1169. There are no stairs in the home.

LPA observed the outdoor area to be fenced and free from hazards LPA observed a children's play equipment to be safe and free on hazards. Licensee ensures that children in care are always supervised. Capacity as specified on the license is being maintained.

Licensee’s pediatric CPR/First Aid was completed on 12/17/22 and the Mandated Reporter Training was Completed on 1/25/24.

Licensee owns her own home. Licensee will send copy of deed to be placed in the file.

This home does not provide Incidental Medical Services . LPA reviewed children’s, personnel, and administrative records. When a child is ill, they will be separated from the other children. Isolation area will be located in the play room until parent picks child up.

For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/

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SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Jeanine LipseyTELEPHONE: (424) 301-3077
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 03/19/2024 08:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: CUA VILLALTA FAMILY CHILD CARE
FACILITY NUMBER: 197419064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above in that Assistant did no complete cpr class after expiration, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Licensee will send date of enrollment to the department by 3/30/24 and then send copy of completed card by 5/15/24. Licensee will send proof by email ot postal mail.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

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 in that 1 out of 3 children's files did not contain form LIC 700 Consent foridentification of Emergency information which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2024
Plan of Correction
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Licensee will provide proof to the department a copy of the missing form via email or postal mail/. jeanine.lipsey@dss.ca.gov
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: Betty BellTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Jeanine LipseyTELEPHONE: (424) 301-3077
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 03/19/2024 08:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: CUA VILLALTA FAMILY CHILD CARE
FACILITY NUMBER: 197419064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
"(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as requiredin Section 102417(g)(7)."

This requirement is not met as evidenced by Child #2 LIC 627 was not available to view.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 1 out of 3 children's files did not contain form LIC 627 Consent for Emergency Medical Treatment, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Licensee will provide the Department with verification of the LIC 627 Consent for Emergency Medical Treament form. Licensee may provide this via emai, text or US Mail. jeanine.lipsey.dss.ca.gov
Type B
Section Cited
CCR
102421(b)

Childs Records: "(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as requiredin Section 102417(g)(7)."

This requirement is not met as evidenced by: Child #2 LIC 700 wan not available to view.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 1 out of 3 children's files did not contain form LIC 700 the emergency information card, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Licensee will provide the Department with verification of the completed form, LIC 700. Licensee may provide this via text or email. jeanine.lipsey.dss.ca.gov
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: Betty BellTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Jeanine LipseyTELEPHONE: (424) 301-3077
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 03/19/2024 08:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: CUA VILLALTA FAMILY CHILD CARE
FACILITY NUMBER: 197419064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(d)(c)
Infant Safe Sleep
Time of each 15-minute check


This requirement is not met as evidenced by: Three infants (C1) , (C2) & (C3) does not have documentation of 15 min infant sleep observations.
Deficient Practice Statement
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Based on record review,, the licensee did not comply with the section cited above by not keeping a sleep log, poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Licensee will provide the Department with verification that all of the 3 children's files contain a copy of the log. Licensee may provide this via email or US Mail.
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: Betty BellTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Jeanine LipseyTELEPHONE: (424) 301-3077
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CUA VILLALTA FAMILY CHILD CARE
FACILITY NUMBER: 197419064
VISIT DATE: 03/15/2024
NARRATIVE
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On this date, 10/07/2013 the California Attorney General - Megan's Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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-and­resources/safe sleep 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.

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SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Jeanine LipseyTELEPHONE: (424) 301-3077
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CUA VILLALTA FAMILY CHILD CARE
FACILITY NUMBER: 197419064
VISIT DATE: 03/15/2024
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEExxxx confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, deficiencies are cited. Technical advisories discussed.

Exit interview conducted and report was reviewed with the licensee Elena Cua Villalta.

A notice of site visit was given and advised Licensee that it must remain posted for 30 days.

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SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Jeanine LipseyTELEPHONE: (424) 301-3077
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 03/19/2024 08:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: CUA VILLALTA FAMILY CHILD CARE
FACILITY NUMBER: 197419064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417g1

Operation of A Family Child Care Home
(1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:fire extinguisher should be serviced yearly, last serviced date 12/13/2021
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, by not having the fire extinqusher serviced yearly, poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Licensee will provide the Department with a copy of the updated servcie tag Licensee may provide this via email or US Mail.
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: Betty BellTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Jeanine LipseyTELEPHONE: (424) 301-3077
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 9 of 9