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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400471
Report Date: 12/01/2021
Date Signed: 12/01/2021 11:49:25 AM

Document Has Been Signed on 12/01/2021 11:49 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:JIMENEZ FAMILY CHILD CAREFACILITY NUMBER:
198400471
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/01/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Tania Jimenez, ApplicantTIME COMPLETED:
12:15 PM
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Prior to entrance to the facility, LPA Lucero conducted a COVID-19 assessment and based on the applicant's responses to the facility assessment questions, LPA Lucero determined it was safe to proceed. On Wednesday, December 1, 2021 at 10:15am, Licensing Program Analyst (LPA) Lucero conducted an announced Pre-Licensing inspection. LPA met with applicant Tania Jimenez. LPA was taken on a guided indoor and outdoor tour of the facility by applicant. There were no minor children present at the time of inspection and LPA did not observe any other adults in the home at time of inspection. Family members residing in the home have been discussed with applicant.

This is a single-story home that consists of entry way, two bedrooms, one bathroom, kitchen, living room, and dining area, and detached garage. Per applicant, areas accessible to children and identified on the facility sketch were inspected by LPA which consists of entry way, living room, dining area, one bathroom, detached garage, front and back yards. Per applicant, areas off-limits to children and identified on the facility sketch are two bedrooms, kitchen, laundry room. LPA observed a door to prevent children from gaining access to off-limits kitchen and laundry room.

At approximately 10:25am, LPA began the facility to inspect for safety, comfort, cleanliness, ventilation and working phone. For ventilation, LPA observed that the facility has open windows and doors. LPA observed a mounted wall heater which applicant states has been turned off by the gas company. LPA obtained copy of receipt from Gas Company indicating inspection made to mounted heater. Applicant states she has portable heaters to heat the rooms.

LPA observed the furniture and children materials to be in good condition and age appropriate. LPA observed the LIC 610A Emergency Disaster Plan, PUB 394 Parent’s Rights posted on the Parent Board at facility entrance.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198400471
VISIT DATE: 12/01/2021
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At approximately 10:35am, LPA observed the restroom and observed the toilet, hand washing sink, running water, towel, and hand soap. LPA observed hand washing poster. Restroom observed to be in good condition.

LPA asked if there are any pets, poisons, firearms, weapons or bodies of water. Applicant stated she does not have any pets. LPA did not observe any bodies of water on the premises. Applicant stated there are no firearms, weapons or poisons. Applicant was advised that if any poisons (ex: Drano, rat poison or items with skull hazard symbol), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition must be stored separately.

LPA observed the fire extinguisher located in the kitchen and the valve on the green area indicating fully charged; LPA observed this to be a 2A10BC. LPA observed the dual smoke detector and carbon monoxide detector (dual device) in the entry way. Applicant tested detector until a beeping sound emanated from the device. The dual smoke and carbon detector appears to be in good condition. At approximately 10:45am, LPA inspected the outdoor area used by children for safety, comfort and cleanliness. LPA observed play areas to be in good condition and age appropriate. LPA observed the detached garage to have children's toys, paints, and art tables. Applicant stated she understood that children may not eat or sleep in detached garage. LPA observed a shelf with heavy items and the shelf was bent from the weight of the items. Applicant is to reinforce the shelf or remove the heavy items from the shelf.

LPA observed applicant's Pediatric First Aid/ CPR card issued by the American Heart Association with completed date of 08/07/2021 and a recommended renewal date of 08/2023 for Pediatric First Aid/CPR. Discussion was held with applicant regarding the importance of maintaining current Pediatric CPR/First Aid certification. Mandated Reporter Training (AB 1207) has been completed. Applicant was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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 also explained to applicant that car seat, stroller are only and only for https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198400471
VISIT DATE: 12/01/2021
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LPA discussed protocol in place in regards COVID-19. Applicant stated protocol in place is having parents not fully enter the facility and sign in and out will take place at the front door entrance. The childcare area is big enough to meet the 6 feet distance. Applicant will scan the children for any symptoms such as fever, running nose, cough or child's behavior and will inform parent child cannot stay if any symptoms related to COVID-19 or if symptoms appear during the day, applicant will isolate the child and call parent for pick up. Children will wash their hands during arrival, entering the facility from outdoor play, mealtimes, covering their cough and using the restroom. LPA observed hand washing posters posted in the bathroom and COVID-19 symptoms poster in the front entrance and hand sanitizer for parents (inaccessible to children). Applicant stated she is aware of cleaning, disinfecting and sanitizing and the importance of the constant hand washing. Technical Assistance was conducted with applicant.

Applicant was unable to obtain Landlord Consent (LIC 9149) and will only be able to care a maximum of six children. LPA obtained Declaration Form (LIC 855 SP) from applicant Tania Jimenez stating that she understands she may only care for a maximum of six children due to not having the LIC 9149. Individual Infant Sleeping Plan (LIC 9227), Infant Sleeping Log, and Safe Sleep Frequently Asked Questions provided.

After review of facility, the following items need to be corrected:
1. Updated LIC 999 (indoor sketch) indicating all bedrooms are now off-limits.
2. Heavy items on shelf in garage removed, or shelf is reinforced.
3. COVID-19 Self-Evaluation Form needs to be filled out and submitted.

Applicant must provide the above mentioned corrections by Close of Business (COB) on Friday, December 3, 2021. Once all requested documents have been submitted, a final review of all documents will be made for the physical file and application will be placed for licensure pending review.

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
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JIMENEZ FAMILY CHILD CARE
FACILITY NUMBER: 198400471
VISIT DATE: 12/01/2021
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Applicant Tania Jimenez 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.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the applicant Tania Jimenez.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4