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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020244
Report Date: 03/06/2025
Date Signed: 03/06/2025 04:27:43 PM

Document Has Been Signed on 03/06/2025 04:27 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:FERNANDO FAMILY CHILD CAREFACILITY NUMBER:
198020244
ADMINISTRATOR/
DIRECTOR:		SHAMILA & TERVINE FERNANDOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 728-7251
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
03/06/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Tervine FernandoTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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On March 6, 2025, at 8:50am Licensing Program Analyst (LPA) A. Carter conducted an Unannounced Annual / Random inspection and met with licensees Shamila & Tervine Fernando. LPA disclosed the purpose of the inspection and was granted entry into the facility. Licensee was provided a copy of the Facility Entrance Checklist.
All adults associated to the home were found to have criminal record clearance. There were eight (8) daycare children present during the initial start of today’s inspection. Licensees’ states there are currently twelve (12) children enrolled. Licensee provides care to children ages ranging from 3 months to 14 years of age. Licensee reports the facility’s hours of operation are Monday through Friday from 6:00am to 6:00pm. Licensee does not provide overnight care but does provide transportation as needed.
  • At 9:25am 2 additional children arrived.
This is a single story home which consists of three (3) bedrooms, two (2) bathrooms, living room, kitchen, dining area and detached garage. Areas used by the children include the living room (main care area), bathroom next to the kitchen, and kitchen in passing. Per Licensee, areas off-limits to children and parents include three (3) bedrooms, one (1) bathroom, and detached garage. The licensee does understand that licensing staff may have access to off-limit areas during inspection visit if necessary. LPA observed off-limits areas doors to be locked making them inaccessible to children in care.

All areas identified on the facility sketch as accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety and comfort of the children.


LPA observed required posted documentation in the main care living room 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 and Disaster drill log, last drill conducted on 01/15/25.
Dual smoke/carbon monoxide detectors observed by LPA were tested and operable at the time of inspection. LPA observed the AB10BC fire extinguisher with receipt purchase date of April 15, 2024. The facility has central air and heating and maintains telephone service via landline and cell phone.
SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Andrea Carter
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: FERNANDO FAMILY CHILD CARE
FACILITY NUMBER: 198020244
VISIT DATE: 03/06/2025
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LPA observed age appropriate toys and learning materials available for children in care, free of loose and sharp parts. LPA did not observe any wall heaters or fire places in the home.The children use the bathroom next to the kitchen. LPA did not observe hazards in the bathroom. Detergents, cleaning compounds, and medications are stored in an off-limits area of the home inaccessible to children in care. The Licensee states that there are no poisons in the home. The Licensee does understand that poison must be locked. The Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. The isolation area for sick children waiting to be picked is the entrance area of the main care area, supervised away from the other children in care. Per licensee, food is provided for children in care. The dining area has toddler tables and chairs set up during meals. LPA reminded licensee that any food brought from the children’s homes shall be labeled with child’s name and properly stored or refrigerated.
Per licensee, the children will have access to the backyard for outside play. LPA observed age appropriate toys for children in care. The play area is covered, providing ample shading for children in care. Per Licensee, children are supervised while playing outside LPA observed yard has grass and adequate perimeter fencing through-out the property. Play area is free of loose and sharp articles or objects and all trees, shrubs, and plants are maintained.

Infant Care: Currently licensees’ have four (4) infants enrolled. Each infant has their own play yard. Infant mattresses were observed to be firm with tightly fitted sheets. LPA did not observe loose object, bumpers, objects hanging, or objects attached to the cribs. Napping equipment does not block entrances or exits. Licensee was advised Infants shall not be swaddled in care. Car seats shall only be used for transportation purposes and shall not be used for sleeping. LPA discussed the new Safe sleep regulation, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for 0-24months.

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 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.
  • Child#2 and Child#3 was missing LIC 9227 form in file
Report continues- Page 2 of 4
SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Andrea Carter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: FERNANDO FAMILY CHILD CARE
FACILITY NUMBER: 198020244
VISIT DATE: 03/06/2025
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Licensees’ records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, Proof of immunizations 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.
—Pediatric CPR / First aid Card valid until: 04/22/25
—Mandated Reporter AB1207 Completed: 01/19/22 valid for 2years. Licensees' will complete required training and submit proof to LPA.
During the inspection, children present was observed to be treated with dignity and respect, observed to be receiving safe, healthful, and comfortable accommodations, furnishings, and equipment, and free from corporal and/or unusual punishment.
· Licensee stated they do not have any children that needs medication administer, or any children with allergies in care at this time.
· Licensee stated that there are no smokers in the home.
· Licensee states there are no pets in the home. LPA did not observe any pets at time of inspection.
· Licensee stated there are no weapons, or firearms in the home.
· Licensee stated there are no bodies of water around the premises. LPA did not observe any bodies of water at time of inspection.

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-and-resources/safe-sleep as an additional resource. Report continues- Page 3 of 4

SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Andrea Carter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: FERNANDO FAMILY CHILD CARE
FACILITY NUMBER: 198020244
VISIT DATE: 03/06/2025
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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.

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 childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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

Based on this information, the following deficiencies on the attached LIC 809D are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

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.



Exit interview conducted and report was reviewed with the licensee Tervine Fernando.

Appeal Rights given

Report ends- Page 4 of 4

SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Andrea Carter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 04:27 PM - It Cannot Be Edited


Created By: Andrea Carter On 03/06/2025 at 11:17 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: FERNANDO FAMILY CHILD CARE
FACILITY NUMBER: 198020244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025

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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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 licensees' had expired Mandated Reporter Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Both licensees' will completed the required Mandated Reporter Training and submit certificate of completion to LPA via email as proof of correct by the agreed upon date.
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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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 infants did not have the required LIC 9227 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensees' will have parents complete the LIC 9227 form for infants in care up to 12months and submit forms to LPA via email as proof of correction by agreed upon 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:Denise Gibbs
LICENSING EVALUATOR NAME:Andrea Carter
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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