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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243909809
Report Date: 08/16/2021
Date Signed: 08/16/2021 12:19:50 PM

Document Has Been Signed on 08/16/2021 12:19 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:AYALA, MANUEL & DOMINICA FAMILY CHILD CAREFACILITY NUMBER:
243909809
ADMINISTRATOR:AYALA, MANUEL & DOMINICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 384-3643
CITY:MERCEDSTATE: CAZIP CODE:
95341
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Manuel and Dominica AyalaTIME COMPLETED:
12:30 PM
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On 08/16/21, Licensing Program Analyst (LPA) Angelica Slaughter conducted an unannounced annual inspection and met with Licensees, Manuel and Dominica Ayala. Licensee's adult daughter was also present during this inspection. A tour of the home was conducted and a census was taken. Current facility sketch reviewed and Licensees confirmed the two living room areas, dining room, kitchen, and hall bathroom are used for providing care and are accessible to day care children. All other rooms are off-limits and are made inaccessible by use of child safety gate preventing access to the second story of the home. There were no swimming pools, bodies of water, or firearms on the premises. Medications and other hazardous items were inaccessible to children. LPA did not observe any poisons in the home. There was no fireplace. The fire extinguisher, smoke detector, and carbon monoxide detector met Community Care Licensing (CCL) regulations. The home was kept clean and orderly, with heating and ventilation for safety and comfort. Stairs barricaded with a child safety gate when children under five years of age present. Safe toys and play equipment were observed. Licensees had a working telephone and the above telephone number was verified. The backyard is currently off-limits to day care children. Licensees ensure that children in care are supervised at all times. Licensees are aware that children shall not be left in parked vehicles and are aware car seats are used for transportation purposes only and are not used for sleeping children.

There are currently two infants in care. LPA discussed Safe Sleep Regulations with Licensees. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping. There are no objects hanging above or attached to the crib or play yard. Licensees physically check on sleeping infants every 15 minutes and document any signs of distress, to include but is not limited to: flushed skin color, increase in body temperature, restlessness, and labored breathing.
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Angelica Slaughter
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: AYALA, MANUEL & DOMINICA FAMILY CHILD CARE
FACILITY NUMBER: 243909809
VISIT DATE: 08/16/2021
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Adequate supervision was being provided during this inspection. Capacity as specified on the license was being maintained. Staff-child ratios were maintained. A sample of children’s records contained all emergency information specified by regulation. There were no excluded individuals present at this home. All adults who reside or work in the home had a criminal record clearance or exemption. A review of records indicated Licensees and all employees and/or volunteers have proof of required immunization (Pertussis/Measles/Influenza) and/or written declaration declining flu shot. Licensees did not have Mandated Reporter Training completed. LPA discussed required Mandated Reporter Training to be completed by 08/23/21. Licensees were reminded the Mandated Reporter Training shall be renewed every two years following the date on which it was initially completed. Licensees pediatric CPR and First Aid expires on 05/02/22.

Incidental Medical Services (IMS) are not currently provided. Licensees are aware that an IMS plan is required to be submitted to the Licensing Office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA information line at (800) 514-0301 (voice), (800) 514-0383 (TDD), and website link: https://www.ada.gov/childqanda.htm.

LPA and Licensees discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms, and Regulations.

Business hours are Monday through Friday 6:00 AM to 9:00 PM and other hours as arranged.

Per Title 22, Division 12, Chapter 3 of the California Code of Regulations, the following deficiencies were found (see next page, 809 D):

Exit interview was conducted with Licensees. Licensees were provided with a copy of the Facility Evaluation Report (LIC 809), appeal rights, and the Notice of Site Visit form (LIC 9213). The LIC 809 is required to remain in the facility for public review and the LIC 9213 is required to be posted for 30 days.
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Angelica Slaughter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2021 12:19 PM - It Cannot Be Edited


Created By: Angelica Slaughter On 08/16/2021 at 11:38 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: AYALA, MANUEL & DOMINICA FAMILY CHILD CARE
FACILITY NUMBER: 243909809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2021
Section Cited
HSC
1596.8662(4)(b)(1)

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Mandated Reporter Training - On or before March 30, 2018..is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training...shall complete renewal mandated reporter training every two years..the initial mandated reporter training. This requirement was not met as
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Licensee's will take the required Mandated Reporter Training and will submit proof to CCLD by the POC due date of 08/23/21.
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evidenced by: Licensees could not produce Mandated Reporter Training Certificates. This posses a potential risk to the health, safety and/or personal rights of children 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:Diana deLeon
LICENSING EVALUATOR NAME:Angelica Slaughter
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021


LIC809 (FAS) - (06/04)
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