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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400478
Report Date: 03/24/2023
Date Signed: 03/24/2023 03:23:17 PM

Document Has Been Signed on 03/24/2023 03:23 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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CASTRO PINEDA & AMAYA FAMILY CHILD CAREFACILITY NUMBER:
198400478
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 2DATE:
03/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Co-Licensee - Ana Iris Castro PinedaTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Randy Derraco condcuted an unannounced case management visit on 03/24/23 to the above mentioned address. LPA arrived at the facility at 12:50 PM and was met by co-licensee Ana Iris Castro Pineda. The purpose of this visit is to observe corrections to citations issued on 01/19/23. LPA observed 1 adult sleeping in bedroom 1. There were 3 children in care. Licensee states there are 5 children total that are enrolled. Licensee states that her daughter is home from school and is confined to bedroom 1 due to illness. LPA observed the home to be clean and in good repair.

LPA observed an infant sleeping in a crib in room 2. The infant was observed sleeping with 3 blankets and a pillow in the crib. The infant was also observed to be sleeping on his stomach. The door to the bedroom 2 was observed to be closed. LPA advised licensee that citations under California Code of Regulation (CCR) section 102525(b) and 102425(j)(5) will be issued.

LPA observed that the licensee had a completed LIC9040 - Children's Roster posted on the parent board. LPA conducted a children's record review. LPA observed a completed LIC 700 - Identification and Emergency Information form on file for both children in care. LPA also observed a completed LIC 995A - Family Child Care Home Notification of Parents' Rights form completed and signed for both children in care. LPA did not observed a completed immunization record for either of the children in care. Licensee states she has the form but is unable to provide the document because it is locked in a file cabinet and she does not have a key. LPA advised that a citation under CCR section 102418(g) will be re-issued. LPA advised that the plan of correction will need to be completed by 03/30/23.

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
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023
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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CASTRO PINEDA & AMAYA FAMILY CHILD CARE
FACILITY NUMBER: 198400478
VISIT DATE: 03/24/2023
NARRATIVE
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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.

LPA provided and discussed PIN 20-24-CCP - Recently approved safe sleep regulations in effect

The following deficiencies listed on the attached LIC 809 (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 notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Ana Iris Castro Pineda.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/24/2023 03:23 PM - It Cannot Be Edited


Created By: Randy Derraco On 03/24/2023 at 02:52 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: CASTRO PINEDA & AMAYA FAMILY CHILD CARE
FACILITY NUMBER: 198400478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2023
Section Cited
CCR
102418(g)

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102418 Immunizations (g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
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Licensee was advised that Plan of Correction will need to be observed by case management visit.
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Based on observation and record review, the licensee did not document children's immunziation which poses a potential Health, safety and/or personal rights risk to persons in care.
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Type B
04/03/2023
Section Cited
CCR102425(b)

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102425 Infant Safe Sleep (b) Cribs or play yards shall be free from all loose articles and objects. This requirement is not met as evidenced by:
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Licensee will review PIN 20-24-CCP - Recently approved safe sleep regualtions in effect and CCLD Safe Sleep webpage. Licensee will provide a summary of Safe Sleep regulations to LPA via email and complete a declaration (LIC855) indicating that they have revieved and understand the material.
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Based on observation and interview, the licensee did not keep the crib free from all losse articles which poses a potential Health, safety and/or personal rights risk to persons in care.
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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:Karen Chambers
LICENSING EVALUATOR NAME:Randy Derraco
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/24/2023 03:23 PM - It Cannot Be Edited


Created By: Randy Derraco On 03/24/2023 at 03:06 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: CASTRO PINEDA & AMAYA FAMILY CHILD CARE
FACILITY NUMBER: 198400478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2023
Section Cited
CCR
102425(j)(5)

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102425 Infant safe sleep (j) The provider shall supervise infants while they are sleeping... (5) If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. This requirement is not met as evidence by:
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Licensee will review PIN 20-24-CCP - Recently approved safe sleep regualtions in effect and CCLD Safe Sleep webpage. Licensee will provide a summary of Safe Sleep regulations to LPA via email and complete a declaration (LIC855) indicating that they have revieved and understand the material.
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Based on observation and interview the licensee did not leave the door open to bedroom 2 while infant was sleeping which poses a potential Health, safety and/or personal rights risk to persons in care.
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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:Karen Chambers
LICENSING EVALUATOR NAME:Randy Derraco
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023


LIC809 (FAS) - (06/04)
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