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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020583
Report Date: 01/12/2022
Date Signed: 01/12/2022 10:44:25 AM

Document Has Been Signed on 01/12/2022 10:44 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:PENA-CAMPUZANO FAMILY CHILD CAREFACILITY NUMBER:
198020583
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 3CENSUS: 0DATE:
01/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Marcela Pena Campuzano TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Judy Mora conducted an unannounced annual required inspection at the above facility on 01/12/2022 at 9:45 AM. Visit was conducted in Spanish. LPA met with Marcela Pena-Campuzano, Licensee who guided analyst on a tour of the facility at approximately 9:50 AM. Licensee's son, Hugo Vera, was present during this inspection. There were no children present at the time of inspection. Facility capacity is in compliance for a small Family Child Care Home. The Licensee has also requested a capacity increase for a Large Family Child Care License. Fire Inspection was approved and the LIC 850 was received by the Department on 01/06/2022.

This is a one-story home which consists of two bedrooms, one bathroom, living room, kitchen/dining room, front yard (fenced) and backyard (fenced). There is also a detached garage/living unit which is not used for the day care; door is kept locked. There is also a shed for storage in the backyard which is kept locked. Per Licensee, areas off limits to children and parents include: Two bedrooms (locked), detached garage/unit. Hours of operation are Mon-Fri 6:00 AM - 6:00PM. 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.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption.

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 12/2021.

*REPORT CONTINUES ON NEXT PAGE
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Judy Mora
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PENA-CAMPUZANO FAMILY CHILD CARE
FACILITY NUMBER: 198020583
VISIT DATE: 01/12/2022
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Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged and was purchased on 11/16/21. 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 and medication are 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. Per Licensee there are no firearms or weapons stored in the home.

Infant Care: Currently licensee does not care for any infants. LPA informed 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.

Currently children are using the backyard yard 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 did not observe any objects that could be hazardous to children in care.

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, 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. The Licensee does not have the Required Mandated Reporter Training on file. LPA will review file to determine if it was completed.

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

*REPORT CONTINUES ON NEXT PAGE
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Judy Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PENA-CAMPUZANO FAMILY CHILD CARE
FACILITY NUMBER: 198020583
VISIT DATE: 01/12/2022
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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

Based on the LPA's observations and records review no deficiencies will be cited.

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.

Exit interview conducted and report was reviewed with the Licensee, Marcela Pena-Campuzano.

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Judy Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC809 (FAS) - (06/04)
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