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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020949
Report Date: 12/02/2024
Date Signed: 12/02/2024 01:12:40 PM

Document Has Been Signed on 12/02/2024 01:12 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:PEREYRA FAMILY CHILD CAREFACILITY NUMBER:
198020949
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 5DATE:
12/02/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Vera Pereyra, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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On December 2, 2024, Licensing Program Analysts (LPAs) Monique Ayala and Mariah Aguirre conducted an unannounced Annual/Random inspection at the above facility. Upon arrival LPA Ayala was greeted by licensee, Vera Pereyra who guided LPAs a tour of the facility. Inspection was conducted in Spanish. LPA observed 5 children in care. Hours of operation are Monday through Friday, 6AM to 6PM.

This is a single-story house with 2 bedrooms and 1 bathroom, laundry area with chemicals and cleaning compounds inaccessible to children in care, living room, dining room, kitchen, completely fenced front yard.

The licensee's requested a capacity increase from 8 children to 14 children on 05/30/2024. The fire clearance was cleared and granted for 14 children on 11/20/2024. The licensee's provided LIC9149 (Landlord consent for 14 children).

The day care takes place in living room, dining room, hallway bathroom, bedroom #1, and rear yard. The home is clean, orderly, comfortable, and well ventilated.

Licensee's poisons, detergent, cleaning compounds, medications and other items which could pose a danger to child are stored where they are inaccessible to children. LPA observed working smoke detector and Carbon Monoxide, fully charged fire extinguisher, and working telephone.

There are several age-appropriate toys and a first aid kit on the premises. Per the licensee, there are no firearms on the premises. Licensee has current First Aid and CPR, expires 10/07/2025.

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PEREYRA FAMILY CHILD CARE
FACILITY NUMBER: 198020949
VISIT DATE: 12/02/2024
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LPA reviewed children files; files were not found to be complete. LPA reviewed staff files; files were found to be complete. Children and staff names were documented on LIC811 (confidential page). Infant did not have sleeping log, LIC9227 or completed file.

The licensee has completed the online mandated reporter training at www.mandatedreporterca.com, expires on 06/02/2025. All childcare employees must complete mandated reporter training within 30 days of hire and renew training every two years



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

Licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B.

The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).

The licensee was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507

Per the licensee, fire and disaster drills are conducted every 6 months; last drill documented and conducted on 11/15/2024.

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024
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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: PEREYRA FAMILY CHILD CARE
FACILITY NUMBER: 198020949
VISIT DATE: 12/02/2024
NARRATIVE
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Licensee has the required documents posted in the FCCH; Facility License (LIC 203), Emergency Disaster Plan (LIC610a), Notification of Parents' Rights Poster (PUB 394).

The following was discussed with the licensee:


Capacity requirements, Roster requirements, Posting requirements, Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children’s files and provider’s files, and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. Licensee was reminded that supervision is always required to children in care.

Licensee was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care. Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified.

Regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category.

--Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.


-- Our Quarterly updates come out every 3 months they are also now in Spanish please log in to the CCLD website or you can email our advocates to have the quarterly updates send directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

The on Duty Worker is available for questions Monday through Friday at (323) 981-3350 from 8:00 AM - 5:00 PM.

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-andresources/safe-sleep as an additional resource.

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024
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: PEREYRA FAMILY CHILD CARE
FACILITY NUMBER: 198020949
VISIT DATE: 12/02/2024
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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.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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

Licensee was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Based on record review, the facility is being cited eight Type B deficiencies in accordance with Title 22 Regulations, see LIC809D.

An exit Interview was conducted, a copy of this report along with Notice of Site visit was provided to the licensee, Vera Pereyra.

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2024 01:12 PM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 12/02/2024 at 12:48 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PEREYRA FAMILY CHILD CARE
FACILITY NUMBER: 198020949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

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 infants do not have a sleeping log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2024
Plan of Correction
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Licensee will complete sleeping log when infants are sleeping every 15 minutes.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 Child #6 did not have current immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2024
Plan of Correction
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Licensee found Child #6's immunizations and showed immunizations to LPAs
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:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2024 01:12 PM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 12/02/2024 at 12:48 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PEREYRA FAMILY CHILD CARE
FACILITY NUMBER: 198020949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

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 Child #1 and Child #6 do not have a signed LIC995A which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Licensee will ensure that the LIC995A is completed and placed in Child #1 and Child #6's file by POC date.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

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 Child #1 and Child #6 did not have an emergency informations card which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Licensee will ensure that the emergency inforamtion card is completed and placed in Child #1 and Child #6's file by POC 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:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2024 01:12 PM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 12/02/2024 at 12:48 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PEREYRA FAMILY CHILD CARE
FACILITY NUMBER: 198020949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

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 Child #1 and Child #6 do not have a signed LIC995A which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Licensee will ensure that the LIC995A is completed and placed in Child #1 and Child #6's file by POC 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:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2024 01:12 PM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 12/02/2024 at 12:48 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PEREYRA FAMILY CHILD CARE
FACILITY NUMBER: 198020949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in Child #1 and Child #6 do not have a signed affidavits which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Licensee will ensure that the affidavits is completed and placed in Child #1 and Child #6's file by POC 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 Child #6 does not have a signed LIC9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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2
3
4
Licensee will ensure that the LIC9227 is completed and placed in Child #1 and Child #6's file by POC 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:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024


LIC809 (FAS) - (06/04)
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