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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011417
Report Date: 05/06/2022
Date Signed: 05/06/2022 12:04:49 PM

Document Has Been Signed on 05/06/2022 12:04 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:LOBOS FAMILY CHILD CAREFACILITY NUMBER:
198011417
ADMINISTRATOR:LOBOS, ALBALINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 960-1789
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Albalina LobosTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fabiola Vasquez conducted an unannounced annual required inspection at the above facility on 05/06/22 at 8:30 AM. Visit was conducted in Spanish. LPA met with Albalina Lobos, Licensee who guided analyst on a tour of the facility at approximately 8:40 AM. There were 0 children present per licensee she has not had children in care since March 2022. Residing in facility are 3 Adults and 0 Children

This is a one-story home which consists of three bedrooms, two bathrooms, kitchen, dining room, living room, detached garage, front and yards (fenced). Per Licensee, areas off limits to children and parents include: All three bedrooms, one bathroom and front yard. Areas accessible to children were inspected as follows: Living room, dining area, kitchen, back yard and garage that has been converted into a day care. Hours of operation are Mon-Fri 6:00 AM - 6:00PM. Food is provided by Licensee.

LPA observed the following required posted documentation in the main entry way of the facility: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA reviewed facility records for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log. Last drill was conducted on 6/14/19.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher expired 8/25/2021. The home maintains telephone service via landline and cell phone. The home was observed to be cluttered and not orderly. LPA observed vitamin containers, pots stalked on top of the stove, containers laying throughout the kitchen counters. Kitchen floor was observed to have dirt spots and small debris. LPA observed boxes and bags on top of the changing table in the children’ restroom. Licensee removed the items and organized during the visit.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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 6
Document Has Been Signed on 05/06/2022 12:04 PM - It Cannot Be Edited


Created By: Fabiola Vasquez On 05/06/2022 at 11:15 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: LOBOS FAMILY CHILD CARE
FACILITY NUMBER: 198011417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

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 the outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA observed the back yard to be cluttered: House appliances, construction tools, power tools, bucket with bags, waterhole in a box, pieces of wood near, containers on the grass with fermenting fruits, , children toys stalked up , lawn mower, ice chest, cement carrier, a piece of pole leaning on the storage, two baby high chairs a bassinet. In the driveway LPA observed cars, pieces of wood, a role of chicken wire and construction paper. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Per licensee, the back yard will be cleaned and submit proof to LPA via email.
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (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:
Deficient Practice Statement
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Based on LPA’s observation, the licensee did not comply with the section cited above in Fire extinguisher expired 8/25/2021. Licensee did not have children in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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Per licensee, will service the fire extinguisher and submit proof to LPA via email by POC.
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:Claudia Guangorena
LICENSING EVALUATOR NAME:Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/06/2022 12:04 PM - It Cannot Be Edited


Created By: Fabiola Vasquez On 05/06/2022 at 11:15 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: LOBOS FAMILY CHILD CARE
FACILITY NUMBER: 198011417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation, the last drill was conducted on 6/14/19, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Per licensee, will submit proof to LPA via email by POC
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation, Staff # 1 and licensee were missing proof, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Per licensee, will submit proof to LPA via email by POC
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:Claudia Guangorena
LICENSING EVALUATOR NAME:Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/06/2022 12:04 PM - It Cannot Be Edited


Created By: Fabiola Vasquez On 05/06/2022 at 11:15 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: LOBOS FAMILY CHILD CARE
FACILITY NUMBER: 198011417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation, Staff # 1 missing proof of TB clearance, he licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Per licensee, she is going to ask her daughter for the most recent results and submit proof to LPA via email by POC
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:Claudia Guangorena
LICENSING EVALUATOR NAME:Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LOBOS FAMILY CHILD CARE
FACILITY NUMBER: 198011417
VISIT DATE: 05/06/2022
NARRATIVE
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There are toys and other age-appropriate material available for children. Per licensee the facility has central heating and air. LPA observed that detergents, cleaning compounds and medication are stored in in an area that is 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 is in the living room away from other children. Per Licensee there are no firearms or weapons stored in the home

Infant Care: Currently licensee is not caring for infants birth to 24 months. LPA discussed with 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.

Children are using the Back yard and driveway for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA observed the back yard to be cluttered: House appliances, construction tools, power tools, bucket with bags, waterhole in a box, pieces of wood near, containers on the grass with fermenting fruits, , children toys stalked up , lawn mower, ice chest, cement carrier, a piece of pole leaning on the storage, two baby high chairs a bassinet. In the driveway LPA observed cars, pieces of wood, a role of chicken wire and construction paper.

Per licensee she is not caring for children, was reviewed and discussed with licensee. Children’s records (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, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months).



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's 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. S#1 is missing proof of TB clearance.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LOBOS FAMILY CHILD CARE
FACILITY NUMBER: 198011417
VISIT DATE: 05/06/2022
NARRATIVE
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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 the LPA's observations and records review deficiencies will be cited today 05/06/22.

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 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.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Albalina Lobos.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6