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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005423
Report Date: 10/06/2022
Date Signed: 10/06/2022 11:36:41 AM

Document Has Been Signed on 10/06/2022 11:36 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:TORRES, ANA ARACELYFACILITY NUMBER:
214005423
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ana TorresTIME COMPLETED:
11:45 AM
NARRATIVE
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On 10/06/2022, Licensing Program Analyst (LPA), Hanson Leong, made an unannounced annual visit to the Ana Torres facility. The LPA was granted entry by the Licensee, Ana Torres. The LPA explained the purpose of the visit to the licensee. Guardian, the department's system for conducting background checks, has confirmed that all the individuals listed on the facility’s roster have been granted permission to work or be present in a childcare facility. The LPA observed the licensee supervising five preschool children. Children's capacity and ratio requirements were observed to be in compliance,

Day-care Area(s): Living Room, Bathroom #1, Bedroom #1 and Backyard

Off Limit Area(s): Kitchen and entire upstairs area ( Bedroom #2, Bedroom #3 and Bathroom #2). All off-limit area(s) are secured with a locked door or a safety gate. The licensee understands that off-limits areas may not be used for childcare during business hours.

The LPA and the licensee both performed careful inspections of the day-care facilities to look for any potential health and safety hazards. Toys and equipment that are suitable for children of the proper age range are provided at the day-care. The building has sufficient lighting and ventilation, and it is free of any defects or conditions that could put the children in its care in risk. The facility is equipped with a first aid kit that is completely loaded with everything that is required for the treatment of injuries. The day-care facility is equipped with a smoke detector, a carbon monoxide detector, and a fire extinguisher that is always ready for use. Every garbage can and power outlet has been covered. Products for cleaning and washing, detergents, and any other materials that could put children in danger are stored out of their reach. The LPA did not find any walkers, bouncers, or other comparable objects during its inspection.
***See Page 2 for continuation***
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: TORRES, ANA ARACELY
FACILITY NUMBER: 214005423
VISIT DATE: 10/06/2022
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Continued, Page 2
There are reportedly no firearms or other weapons on the premises, as stated by the licensee. The LPA found that the facility did not have any pools, spas, or other types of bodies of water of any kind.

The LPA observed that the licensee had posted all the required forms, including the facility license, Notification of Parental Rights, Earthquake Preparedness Checklist, and Notification of Personal Rights. The licensee is aware that smoking is not permitted in a family childcare facility.

The LPA reviewed the records of five children. All required forms were in the children’s’ file except for one newly enrolled child. The LPA informed the licensee that the newly enrolled child must have the required forms,LIC 282, LIC 627, LIC 700. LIC 995A in their file. The LPA informed the licensee that she will be issued four Type B violations for not having the four required documents for the newly enrolled child.

The LPA has informed the licensee that a Plan of Correction would be provided for all Type B violations. This Plan of Correction will enable the licensee to correct the violations. 

The LPA reviewed the records of the licensee. All required forms were in the files of the licensee. Review of the licensee's training records shows that the licensee is current with her Pediatric First Aid / CPR certifications.

According to the licensee, the facility complies with child care regulations by conducting bi-annual earthquake and fire drills and documenting the results.

The 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.



Incidental Medical Services (IMS) policy was discussed with the licensee. For IMS information, see Evaluator Manual Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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 the publication: **See Page 3 for continuation***

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: TORRES, ANA ARACELY
FACILITY NUMBER: 214005423
VISIT DATE: 10/06/2022
NARRATIVE
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Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The LPA reminded the licensee as of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.



The LPA encouraged the licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

A copy of this report, the “Notice of Site Visit,” and their appeal rights were given to the licensee.

A “Notice of Site Visit” must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted, and the report was reviewed with the Licensee, Ana Torres
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/06/2022 11:36 AM - It Cannot Be Edited


Created By: Hanson Leong On 10/06/2022 at 10:09 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TORRES, ANA ARACELY
FACILITY NUMBER: 214005423

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not have the form, LIC 627, in the child's file, which poses a potential health, safety or personal rights risk to children in care.
POC Due Date: 11/07/2022
Plan of Correction
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LIcensee will provide a copy of the LIC 627 to the department
Type B
Section Cited
CCR
102418(g)
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:
Deficient Practice Statement
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Based on interview and record review, the licensee did not have immunization records in the child's file, which poses a potential health, safety or personal rights risk to children in care.
POC Due Date: 11/07/2022
Plan of Correction
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LIcensee will provide a copy of the immunization records to the department.
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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Hanson Leong
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


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Document Has Been Signed on 10/06/2022 11:36 AM - It Cannot Be Edited


Created By: Hanson Leong On 10/06/2022 at 10:09 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TORRES, ANA ARACELY
FACILITY NUMBER: 214005423

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022

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 interview and record review, the licensee did not have the form, LIC 995A, in the child's file, which poses a potential health, safety or personal rights risk to children in care.
POC Due Date: 11/07/2022
Plan of Correction
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Licensee will provide a copy of the LIC 995A to the department.

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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Hanson Leong
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2022 11:36 AM - It Cannot Be Edited


Created By: Hanson Leong On 10/06/2022 at 10:41 AM
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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TORRES, ANA ARACELY
FACILITY NUMBER: 214005423

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
(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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Based o interview and record review, the licensee did not have the form, LIC 282, in the child's file, which poses a potential health, safety or personal rights risk to children in care.
POC Due Date: 11/07/2022
Plan of Correction
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Licensee will provide a copy of the LIC 282 to the department
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Hanson Leong
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


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