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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019103
Report Date: 10/25/2022
Date Signed: 10/25/2022 04:10:46 PM

Document Has Been Signed on 10/25/2022 04:10 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:
198019103
ADMINISTRATOR:ELIA PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 249-3759
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 5DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Licensee Elia Perez TIME COMPLETED:
04:15 PM
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On 10/25/22 Licensing Program Analyst (LPA) Jeanette Estrada conducted an unannounced required 1 year inspection at the above facility. LPA met with the Licensee Elia Perez and informed her of the purpose for the visit. LPA was assisted by Licensee's daughter-in-law, Bera Portugal, during the inspection. The Licensee was present in the facility but was unavailable due to recovering from a medical procedure. LPA provided Facility Representative with a copy of the Facility Entrance Checklist. There were 7 children and 4 adults present during the inspection. All residents were noted and verified. Present during the inspection was Adult 4 -Aracely Ferrer. Adult 4 is not associated to the facility. LPA verified through the Licensing Information System that Adult 4 has a criminal record clearance. Licensee provided an LIC 9182 for Adult 4 and states she recalls submitting it to the RO. Facility provides care to children ages 6 months to 12 years. Facility is open Monday to Friday 6AM to 6 PM.
This is a one story home with 4 bedrooms, 2 bathrooms, living room, kitchen, dining room, day care room, backyard and detached garage.

Off Limit Areas: Two of the bedrooms in the home are off limits and have safety knobs installed, the restroom in one of the off limit bedrooms and the detached garage.

Per Licensee areas on limits to children are: 2 bedrooms, one bathroom, living room, dining room and daycare room and backyard.


All areas that are accessible to children were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection: LPA observed required posted documentation- Facility license, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA observed and reviewed a current roster LIC 9040 and a current disaster drill log. Last disaster drill was performed in 10/20/22. There is an operable carbon monoxide detector in the kitchen and an operable smoke detector in the day care room. LPA observed a 2A10BC Fire Extinguisher in the kitchen which indicated full and was last serviced December 2021.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Jeanette Estrada
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 198019103
VISIT DATE: 10/25/2022
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The home maintains telephone service (cell phone and landline). Food is provided by Licensee. Licensee was reminded if children bring food from home it must be labeled with the child’s name and properly stored or refrigerated.
There are toys and other age appropriate materials available for children to use in the day care room and in the backyard. Sharp objects, detergents and cleaning compounds were inaccessible to children in care. Knives are kept above the microwave out of reach of children, Cleaning products and laundry products are kept in the garage. Personal medication is kept in an off limits bedroom. Per facility representative, no children enrolled require medication. The facility has central air and heating. There is a barricaded fire place in the living room. Children nap in the day care room and in one of the bedrooms and they are provided appropriate napping equipment. Children use the restroom in the hallway.
Children use the backyard for outdoor play. LPA observed the back yard is fully enclosed. Per Licensee, children are supervised while playing outside. Per facility representative, there are no poisons in the home. LPA advised that all poisons must be locked, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in the living room, separated from other children. Per facility representative, there are no firearms or weapons stored in the home. LPA did not observe any pools or spas, or other bodies of water. There are no pets in the home.
Infant Care: Currently licensee has 2 infants enrolled. LPA observed two cribs in the day care room. LPA observed the cribs to be free from blankets and loose items. Licensee was advised Infants shall not be swaddled in care. Car seats shall not be used for sleeping.
Overnight Care: There is no overnight care provided at the moment. LPAs discussed the following: Licensee is aware that they must remain awake while children are awake. If children sleep in separate area from licensee, the door must remain open. If licensee cannot hear children when they wake up, video or audio device can be used.Children's records were reviewed: Children's records contained Immunization Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights and the 15 minute infant sleep log.
Staff records were reviewed: Licensee has current pediatric CPR/First Aid which expires 9/2023, Mandated Reporter training which expires 2/27/2024. Licensee has required immunization vaccines on file for pertussis, measles and influenza. Adult 4 was also assisting with the children in care. Adult 4 did not have Mandated reporter training and proof of required immunizations on file.
During inspection the children present was observed to be treated with dignity and respect, and free from corporal and/or unusual punishment.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Jeanette Estrada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
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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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 198019103
VISIT DATE: 10/25/2022
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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
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. A type B citation is being issued for Adult 4 not having a completed criminal record transfer. Per facility representative, LIC 9182, LIC 508 and a copy of Adult 4's ID will be submitted to the RO by COB 10/26/22.
LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleephttps://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. 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.
The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D for Type B citations. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.
Exit interview conducted and report was reviewed with Facility Representative Bera Portugal . A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Jeanette Estrada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2022 04:10 PM - It Cannot Be Edited


Created By: Jeanette Estrada On 10/25/2022 at 03:40 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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 198019103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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4
Based on record review, the licensee did not comply with the section cited above. Adult 4/ Assistant did not have mandated reporter certificate on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2022
Plan of Correction
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Licensee will have adult 4 complete the mandated reporter training, general and child care provider course and will submit proof to LPA via email. LPA advised training can be completed on www.mandatedreporterca.com
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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4
Based on Record review, the licensee did not comply with the section cited above. Adult 4 did not have proof of required immunizations for Measles, pertussis and Flu on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2022
Plan of Correction
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4
Licensee will obtain proof of required immunizations for adult 4 and will submit proof to LPA via email.
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:Jeanette Estrada
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/25/2022 04:10 PM - It Cannot Be Edited


Created By: Jeanette Estrada On 10/25/2022 at 03:40 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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 198019103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102370(d)(2)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 102370(j) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review the licensee did not comply with the section cited above in 1 out of 4 adults present who did not appear on the facility roster which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2022
Plan of Correction
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4
Licensee will submit LIC 9182, LIC 508 and a copy of an ID to the Regional Office to have the transfer request for Adult 4, Aracely Ferrer, completed.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above. adult 4 did not have proof of requried immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2022
Plan of Correction
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4
Licensee will obtain proof of required immunizations for adult 4 and will submit proof to LPA via email.
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:Jeanette Estrada
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022


LIC809 (FAS) - (06/04)
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