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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198009629
Report Date: 07/27/2022
Date Signed: 07/27/2022 05:54:50 PM

Document Has Been Signed on 07/27/2022 05:54 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:RIVAS FAMILY CHILD CAREFACILITY NUMBER:
198009629
ADMINISTRATOR:RIVAS, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 496-2059
CITY:HAWAIIAN GARDENSSTATE: CAZIP CODE:
90716
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Guadalupe Rivas, LicenseeTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Alicia Mooberry conducted a Required Annual Inspection in Spanish on this date. LPA met with Guadalupe Rivas, Licensee and provided the inspection Entrance Checklist, LIC 126. Licensee provided tour of facility. LPA inspected rooms/areas on the facility sketch in which child-care services are provided and to which children have access. Upon arrival at 1:06pm LPA observed 10 children with licensee, also present was Licensee’s teenage daughter.

At 1:08pm LPA observed Child #1, age 4, sitting in a car seat. Additionally, Child #6, Age 5 was laying in a play yard playing during naptime. Licensee was advised that this is a violation of a child's personal rights. This poses an immediate risk to the personal rights of children in care. Licensee, removed children and placed them on sofa for napping. Per licensee the hours of operation are Monday-Sunday 4:00am-12:00am.



This is a two story home with five bedrooms and four bathrooms.
Areas Accessible to children in care: Living room (main daycare area). The dining room is used for napping, bathroom by dining area, kitchen, front yard.
Off limit areas: Entire second floor consisting of Four (4) bedrooms and three (3) bathrooms. First floor: Attached garage (by bathroom), Bedroom ( by bathroom), backyard. There is a baby gate at the foot of the stairs to keep children in care from accessing the second level.

Child care children use the bathroom located in the hallway next to the dining room.
Individuals residing in the home were discussed and noted.
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:

Page 1 – Report Continues

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Alicia Mooberry
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 198009629
VISIT DATE: 07/27/2022
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LPA observed required posted documentation in facility entrance which included: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA observed completed facility records including; LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan.
The Smoke and Carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged with purchase receipt dated 03/2021, Licensee was reminded that fire extinguisher needs to be serviced yearly. The home maintains telephone service via cell phone. The home is observed to be clean and orderly. There are toys and other age appropriate material available for children.

LPA observed that detergents, cleaning compounds are in the kitchen inaccessible to children. Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in living room, away from the other children. Per Licensee there are no firearms or weapons stored in the home.



The bathroom that children use is located in the observed to be clean and free of hazards.

Infant Care: LPA observed Child #2, age 10 months, to have a pacifier with beads clipped to the clothing, Child #3, had a pacifier attached to a gold chain, this poses a potential risk to the health and safety of children in care. LPA observed that play yards had blankets and pillows. LPA provided Technical Assistance to licensee in Spanish regarding 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. Licensee states the following a sleep supervision plan for infants: Infants sleep in the living room where they will be supervised, licensee and Assistant will ensure to follow the safe sleep regulations.

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 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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SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
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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: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 198009629
VISIT DATE: 07/27/2022
NARRATIVE
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Currently, children are using the front yard for outdoor play. The outdoor play area was observed to be fenced. Licensee has a two-level wooden and plastic playground (in good condition) set including swings. Swings have been secured to the top beam and access to the top level has been removed. LPA observed that the outdoor yard has other age appropriate toys and materials for children to play with. Facility has no bodies of water.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, and documentation of 15-minute Infant Sleep Check (0-24 months)


-Nine (9) out of ten (10) records reviewed did not have immunization records
-Two out of two infant records were missing Infant sleep logs, one infant is missing the LIC 9227 Infant sleep plan.
-Eight out of ten children had incomplete LIC 700 ID and Emergency information

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.

LPA provided licensee with LIC 279 and LIC 279A to complete with updated information including adults and children living in the home and phone number.

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



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

-------------------Page 3 – Report Continues

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
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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: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 198009629
VISIT DATE: 07/27/2022
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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.

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.

Based on the LPA's observations and records review the following deficiencies will be cited today in accordance with California Title 22 Regulations. See 809D

Upon receipt of this report, the Licensee shall post the Notice of Site visit and any licensing report documenting a type “A” deficiency. The report and the Notice of Site visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty.


A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent.Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.
A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Guadalupe Rivas, Appeal Rights were discussed and provided.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 07/27/2022 05:54 PM - It Cannot Be Edited


Created By: Alicia Mooberry On 07/27/2022 at 04:07 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 198009629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Staffing Ratio and Capacity
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type A
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 10 children were not provided safe and comfortable accomodations, Child #1, age 4, was sitting in a car seat and Child #6, Age 5 was laying in a play yard during nap time which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
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Licensee removed the children from the car seat and play yard and placed then on the sofa to nap. Licensee stated they wil ensure children have safe and comfortable accomodations while in care.
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:Valarie Cook
LICENSING EVALUATOR NAME:Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


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Document Has Been Signed on 07/27/2022 05:54 PM - It Cannot Be Edited


Created By: Alicia Mooberry On 07/27/2022 at 04:07 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 198009629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 4 out of the 4 play yards observed had blankets and pillows inside and were missing a fitted sheet to cover the mattress which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
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Licensee removed the lose items from the play yards. Per licensee they will review the Safe Sleep Regulations (PIN 20-24-CCP) and ensure licensee and staff follows the regulations. A written declaration obtained during visit.
Type B
Section Cited
CCR
102425(b)(1)(A)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (1) Pacifiers shall be allowed in the crib or play yard if the following provisions are in place: (A) There shall not be anything attached to the pacifier.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 infants in care were observed with pacifiers with attachments. Child #2, age 10 months, had a pacifier with beads clipped to the clothing, Child #3, had a pacifier attached to a gold chain, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
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Licensee removed the attachements to the pacifiers of Child #2 and Child #3. Per licensee they will review the Safe Sleep Regulations (PIN 20-24-CCP) and ensure licensee and staff follows the regulations. A written declaration obtained during visit.
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:Valarie Cook
LICENSING EVALUATOR NAME:Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 07/27/2022 05:54 PM - It Cannot Be Edited


Created By: Alicia Mooberry On 07/27/2022 at 04:07 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 198009629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

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 8 out of 10 children's records were missing physician name and contact information which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Per licensee, the Children's files will be reviewed and the missing information will be completed. Proof of compeltion will be sent to the Department by POC due date.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) 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 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 9 out of 10 records reviewed were missing proof on immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Per licensee, the Children's files will be reviewed and the missing immunizations will be collected from parents. Proof of completion will be sent to the Department by POC due date.
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:Valarie Cook
LICENSING EVALUATOR NAME:Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 07/27/2022 05:54 PM - It Cannot Be Edited


Created By: Alicia Mooberry On 07/27/2022 at 04:07 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 198009629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in Child #2 infant of 10 minths is missing the Infant sleep plan LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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2
3
4
Per licensee an Individual Sleep plan will be completed by the parents of CHild #2 and a copy provided to the department by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Valarie Cook
LICENSING EVALUATOR NAME:Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


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