198019571-12-21-2021-54-CC-WBIS-C9WRFK-20211221115915

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198019571
Report Date: 12/21/2021
Date Signed: 12/21/2021 11:59:31 AM

Document Has Been Signed on 12/21/2021 11:59 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	VALENZUELA FAMILY CHILD CARE		FACILITY NUMBER:	198019571
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 5	DATE:	12/21/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Dolores Valenzuela		TIME COMPLETED:	12:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Warren Birks conducted an unannounced Case Management inspection due to the Licensee requesting a capacity. LPA met with Licensee Dolores Valenzuela who guided analyst on a tour of the facility. Individuals residing in the home remain the same and was noted. The applicant is requesting a Large Family Childcare license. Per Licensee, hours of operation will be five days a week Monday through Friday from 7:00am to 5:00pm. Applicant states that they will care for children 0-12 years of age. PA observed Licensee caring for five children (three preschool and two infants); which is in compliance with Title 22 ratio and capacity. All areas identified on the facility sketch were inspected. This is a one story home consisting of three bedrooms, two restrooms, living room, kitchen, dining area, and back yard. The home has central air and the Licensee uses the living room, dining area, two front bedrooms, one bathroom, and backyard for childcare. All other areas are off limits to the children. The areas used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation, heating (central air). Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children were inaccessible at this time. LPA advised Licensee to install a door knob cover to ensure the room remains inaccessible at all times (in case Licensee forgets to lock with key). The children will use the fenced back yard for outdoor play. LPA observed barriers on both sides of the house to ensure that yard equipment, grills, and other potentially hazardous items are inaccessible. The Licensee has one small dog that is accessible to children. LPA advised Licensee to block part of the backyard so the dog has it's own area or conduct a daily walk through before children arrive. Per Licensee, there are no bodies of water on the premises. The valve on the fire extinguisher indicates fully charged and is due for service by July 19, 2022. Smoke and carbon monoxide detectors were tested and are operable. The applicant has completed the required Health and Safety Training, Nutrition Training and Pediatric First Aid and CPR which expires October 31, 2023. There are first aid supplies available (includes band aids and thermometer).

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Warren Birks
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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 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: VALENZUELA FAMILY CHILD CARE	FACILITY NUMBER: 198019571
	VISIT DATE: 12/21/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Licensee provides food for children in care unless parents choose to bring their own food. Food bought from the children’s homes are labeled with child’s name and properly stored or refrigerated. The following was discussed with the applicant:

· Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Civil Penalties will be assessed if not in compliance.
· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification and a valid criminal record clearance associated to the facility license.
· Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
· The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked and batteries replaced as needed.
· Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
· Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a family child care home.
· Children and Staff records must be maintained and updated as needed and must be available for review.
· No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility. Smoking on the premises is prohibited.

· All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
· Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

· Liability Insurance was discussed. LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information,

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Warren Birks
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 2 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: VALENZUELA FAMILY CHILD CARE	FACILITY NUMBER: 198019571
	VISIT DATE: 12/21/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

· H&S 1597.622: 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. The licensee and all adults working with children have proof of immunizations.

· Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com. Mandated Reporter training expires August 21, 2021.

LPA advised the applicant to sleep infants where they can be directly supervised at all times and informed her to conduct mandatory periodic checks according to PIN 20-24-CCP if infants sleep in a separate room. The Licensee states she will sleep infants in a separate room and will conduct periodic checks according to PIN 19-02-CCP Safe Sleep Awareness Campaign which has links to information on Safe Sleep and SIDS. Note: LPA provided an additional LIC 9227 to Licensee for review during a previous inspection..

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

LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms:

CHILDREN FORMS/RECORDS - Children’s files must contain the following documents/information:

Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), Consent/Verification for Nebulizer Care (LIC 9166), California School Immunization Record, Parent Notification for Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Acknowledgment of Receipt of Licensing Reports (LIC 9224).--4 of

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Warren Birks
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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: VALENZUELA FAMILY CHILD CARE	FACILITY NUMBER: 198019571
	VISIT DATE: 12/21/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records: As required in Title 22 Regulations 102416.1, Unusual incident/Injury Report (LIC 624B): Child Care Facility Roster (LIC 9040), Notice of Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108), Property Owner/Landlord Consent (LIC 9149), Property Owner/Landlord Notification Form (LIC 9149).

INFORMATION TO BE POSTED IN YOUR FAMILY CHILD CARE HOME – You are required by Law to post the following:
Facility License (LIC 203), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parent’s Rights (PUB 394). A Notice of Site Visit (LIC 9213): Must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

LPA once again discussed PIN 2024 CCP regarding safe sleep and discussed capacity and ratio requirements for a Large Family Child Care Home (Specifically that a Licensee must adhere to Small Family Childcare Ratio and Capacity when she has no qualified assistants present). LPA also discussed care and supervision.

Based on inspection, documentation and capacity/ratio compliance on two unannounced visits, LPA Birks will recommend that Licensee Dolores Valenzuela be approved for a Large Family Child Care License (12 to 14 children). The Capacity increase application will be submitted to management for review and final approval. Once licensed, a Licensee is required to adhere to the terms and limitation as stated on the license.

Exit interview was conducted with Licensee Dolores Valenzuela. The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Warren Birks
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4