198400441-11-9-2022-54-CC-DGIS-CKZT32-20221109132136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400441
Report Date: 11/09/2022
Date Signed: 11/09/2022 01:21:47 PM

Document Has Been Signed on 11/09/2022 01:21 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	CORNEJO FAMILY CHILD CARE		FACILITY NUMBER:	198400441
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 7	DATE:	11/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Maritza Cornejo, Licensee		TIME COMPLETED:	10:44 AM

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 Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 11/9/22 at 9:40AM. LPA met with Maritza Cornejo, Licensee who guided analysts on a tour of the facility. LPA observed seven children upon arrival, five of the children are Infants under two years old and two of the children are over two years old. Facility capacity is not in compliance for a Small Family Child Care Home. LPA provided capacity worksheet for a small and large Family Child Care Home. Also present in the home were two qualified assistants. This is a Two-story home that consists of four bedrooms and two bathrooms upstairs and living room, dining room, foyer, kitchen, laundry area, break room, one bathroom, front yard (not fenced), backyard (fenced), and detached garage downstairs. Main care areas include living room, dining room and back yard. Off limit areas include, four bedrooms and two bathrooms upstairs made inaccessible with child safety gates at the bottom and top of stairs and detached garage in the backyard (locked). Hours of operation are Mon-Fri 7:30 AM - 5:45PM. 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. All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection: LPA observed required posted documentation in facility entrance which included: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. --------------------Page 1

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CORNEJO FAMILY CHILD CARE	FACILITY NUMBER: 198400441
	VISIT DATE: 11/09/2022

NARRATIVE

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Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on 9/5/22.

Dual smoke and carbon monoxide detector was tested and is operable. Fire extinguisher indicated fully charged. Service tag was discussed with licensee.

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 a faux fire place in the living room. LPA observed that detergents, cleaning compounds and medication are stored in kitchen under the sink with child locks, 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. Isolation area for sick children waiting to be picked up is in the living close to the exit, away from the other children. Per Licensee there are no firearms or weapons stored in the home.

The bathroom that children use is located toward the back of the home near the exit door. Bathroom was observed to be clean and free of hazards. Kitchen is used as a walkway to the bathroom.

Infant Care: Currently licensee cares for five infants (12, 14, 18, 19 and 20 months). Older infants naps on a cots. LPA observed three play yards in the main care area. Napping equipment does not block entrances or exits. 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/play yards. There are currently no infants with pacifiers. Per licensee wet or soiled sheets are changed as needed. Each infant has their own play yard and bedding. Bedding is washed weekly by parents. Licensee states the following a sleep supervision plan for infants: Infants nap in main care area where they are supervised at all times.

Outdoor play area is located in the back yard. LPA observed that the yard is fenced and free of hazards. There are two spaces for outdoor play, the main yard and a smaller enclosed sand/garden area on the side of the house. There are no pools or spas, or other bodies of water. Licensee has small dog that stays upstairs during operating hours. Detached garage was observed to be locked.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's ----------------------------Page 2

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CORNEJO FAMILY CHILD CARE	FACILITY NUMBER: 198400441
	VISIT DATE: 11/09/2022

NARRATIVE

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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). All documents were observed.

Staff records were reviewed for approved Pediatric First Aid and CPR certification 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 and current Mandated Reporter Training Certificate. All documents were observed.

During inspection children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

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, the following deficiencies listed on the attached LIC 809D (deficiency page) 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.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.

To improve the quality and value of the new inspection process, a survey will be sent to the email address -------------------------Page 3

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CORNEJO FAMILY CHILD CARE	FACILITY NUMBER: 198400441
	VISIT DATE: 11/09/2022

NARRATIVE

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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, Maritza Cornejo

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/09/2022 01:21 PM - It Cannot Be Edited

Created By: Denise Gibbs On 11/09/2022 at 12:44 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CORNEJO FAMILY CHILD CARE	FACILITY NUMBER: 198400441
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102416.5(b)(2)

Staffing Ratio and Capacity

(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (2) Six children, no more than three of whom may be infants; or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed five infants in care and two children over two, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/11/2022
	Plan of Correction
1 2 3 4	Per Licensee, she will dis-enroll one infant immediately and begin the process to apply for a large family child care home license. Licensee will email notification provided to parent of infant who will no longer be enrolled by 11/11/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Trevino Cochran

LICENSING EVALUATOR NAME:

Denise Gibbs

LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC809 (FAS) - (06/04)

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