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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020949
Report Date: 05/20/2022
Date Signed: 05/20/2022 11:57:24 AM

Document Has Been Signed on 05/20/2022 11:57 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:PEREYRA FAMILY CHILD CAREFACILITY NUMBER:
198020949
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Vera PereyraTIME COMPLETED:
12:10 PM
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On May 20, 2022 Licensing Program Analyst (LPA) Lissete Gonzalez conducted an announced pre-licensing inspection for the above address. LPA met with Vera Pereyra, Applicant, who guided LPA on a tour of the facility. Individuals residing in the home were discussed and noted. Per Applicant, hours of operation will be from 6:00AM to 8:00PM from Monday to Sunday and will not exceed 24 hour care at anytime. Applicant states that she will care for children age birth to 11 years of age.

This is a one-story home which consists of 2 bedrooms, 1 bathrooms, dining room, kitchen, living room, front yard, and side yard. The children will use 1 bedroom, 1 bathroom, dining room, kitchen, living room, front yard, and side yard. Areas off limits to children and parents include 1 bedroom and the back yard. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.
The off limit bedroom was observed to have a lock and applicant states the bedroom will remain locked during operating hours.

Knives and other sharp utensils are located in high cabinet in the kitchen. Cleaning products were located in an upper kitchen cabinet that was observed to have a lock. LPA observed child safety latches under the sink in kitchen and in the lower kitchen cabinets.

The home is clean and orderly. There are outlet covers throughout the home. Smoke detectors and carbon monoxide detector were observed, tested and found to be operable. The open face wall heater located in the living room was observed to be screened and inaccessible.

Applicant has completed the required health and safety training, the Pediatric First Aid and CPR Exp: 9/2023. Applicant has proof of immunization against pertussis and measles, influenza. Proof of Mandated Reporter
REPORT CONTINUES ON NEXT PAGE: 1 OF 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PEREYRA FAMILY CHILD CARE
FACILITY NUMBER: 198020949
VISIT DATE: 05/20/2022
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Training was also submitted. Applicant states she will provide food for children in care. Applicant states there are no pets.

LPA observed age appropriate toys and learning materials. The required (2A10BC) fire extinguisher was observed in the kitchen. First Aid kit is available. Per Applicant, there are no weapons or firearms in the facility, none were observed by LPA.

Per applicant, the front yard (fenced) and side yard (fenced) will be used for outdoor play. Per applicant, children will be supervised at all times during outdoor play in the backyard. Age appropriate toys were available. LPA did not observe any bodies of water on the premises.

LPA provided the Safe Sleep regulation and provided PIN 20-24-CCP and the Infant Sleep Plan LIC 9227 for when Applicant is ready to enroll infants. Children and infants will nap in the daycare room.
LPA discussed the safe sleep regulations with applicant 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 applicant 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.

LPA reviewed with applicant that napping equipment should not block entrances or exits. Infant mattresses must be firm with tightly fitted sheets. Loose object, bumpers, objects hanging, or objects attached to the cribs/play yards are not allowed. Each infant should their own crib/ play yard and bedding. LPA informed applicant 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, and provided PIN 20-24-CCP. Applicant states the following sleep supervision plan: infants: will sleep in the day care room or living room where they will be visually supervised.

LPA discussed self-assessment and answered question regarding COVID-19 procedures. LPA advised applicant to ensure they are following the guidance from the local health authorities in order to prevent and
REPORT CONTINUES ON NEXT PAGE: 2 OF 4
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PEREYRA FAMILY CHILD CARE
FACILITY NUMBER: 198020949
VISIT DATE: 05/20/2022
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reduce the transmission of diseases.

The isolation area for a sick child waiting to be picked up will be in the dining room area of the home.

The following was discussed with the applicant:
· 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 adult/infant CPR & Pediatric First Aid certification, TB clearance, immunization, Mandated Reporter training certificate www.mandatedreporterca.gov, and a valid criminal record clearance associated to the facility license. A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.
· 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 by the Department.
· 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.
· Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
· The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.
· Isolation for Ill children: When a child is ill he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).
· Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information. Licensee states she does not have liability insurance. But will look into it.

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.
REPORT CONTINUES ON NEXT PAGE: 3 OF 4
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PEREYRA FAMILY CHILD CARE
FACILITY NUMBER: 198020949
VISIT DATE: 05/20/2022
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OTHER INFORMATION THAT WAS DISCUSSED:
· Never Shake a Baby, Sudden Infant Death Syndrome (SIDS) and Safe Sleeping practices.
Per applicant, there are no dual licenses at this address.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:
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: http://www.ada.gov/childqanda.htm

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Based on today’s pre-licensing inspection, a small family child care license will be granted. Once licensed, the applicant is required to comply with the terms and limitations stated on the license.

Exit interview conducted and report was reviewed with the applicant, Vera Pereyra.

END OF REPORT PAGE: 4 OF 4
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4