304300905-7-10-2023-06-CC-CNGN-CTLP9C-20230710110655

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304300905
Report Date: 07/10/2023
Date Signed: 07/10/2023 11:07:06 AM

Document Has Been Signed on 07/10/2023 11:07 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	JACOBO-SEGUIN, CORINNE		FACILITY NUMBER:	304300905
ADMINISTRATOR:	JACOBO-SEGUIN, CORINNE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 638-7510
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 6	DATE:	07/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Assistant, Angelica Rojas		TIME COMPLETED:	11:30 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	An Annual Required inspection was conducted at the facility by Licensing Program Analyst (LPA) Cindy Nguyen. LPA observed two assistants caring for one infant, two preschool, and three school age children. Licensee arrived at 9:45am from the store. The facility was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are three adults including the licensee living in the facility. During today’s inspection, LPA and assistant, Angelica Rojas, toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of baby gates and locked doors. The childcare areas include the day care room, the room next to the day care (infant room), and the bathroom by the infant room. There are working carbon monoxide, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. There is an open-faced heater in the living room screened by a metal cover and inaccessible to children in care. The home has age-appropriate toys for the ages served. LPA verified there is a working cellular service. Licensee stated they use the back yard as an outdoor play area. There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible. There are no bodies of water on the premises. The licensee does have a current roster of children in care. Children’s records were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Parents rights (LIC 995A), consent for emergency medical treatment (LIC 627), and immunization records were found to be in compliance. (Page 1 of 3)

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

Document Has Been Signed on 07/10/2023 11:07 AM - It Cannot Be Edited

Created By: Cindy Nguyen On 07/10/2023 at 10:11 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: JACOBO-SEGUIN, CORINNE	FACILITY NUMBER: 304300905
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(b)(1)(A)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. (1) Pacifiers shall be allowed in the crib or play yard if the following provisions are in place: (A) There shall not be anything attached to the pacifier. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the facility did not comply with the section cited above in having a baby beech pacifier clip attached to the pacifier, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2023
	Plan of Correction
1 2 3 4	Assistant, Angelica Rojas immediately, removed the pacifier clip from the child.

Type B

Section Cited

CCR

102425(i)

Infant Safe Sleep

If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the facility did not comply with the section cited above in having an infant on the sway swing sleeping, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2023
	Plan of Correction
1 2 3 4	Assistant Angelica Rojas stated the child had just fallen to sleep about 2 mins before LPA arrived to the facility. Assistant removed child to the play yard right away.

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:

Patricia Magana

LICENSING EVALUATOR NAME:

Cindy Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: JACOBO-SEGUIN, CORINNE	FACILITY NUMBER: 304300905
	VISIT DATE: 07/10/2023

NARRATIVE

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During staff file review licensee’s Pediatric CPR/First Aid certification expired 05/13/2025. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. During staff file review licensee’s mandated reporter certificate expired 11/03/2024.

The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

CCLD website www.cdss.ca.gov/inforesources/community-care-licensing was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.

LPA discussed the safe sleep regulations with licensee Jacobo-Seguin, Corinne 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.

(Page 2 of 3)

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: JACOBO-SEGUIN, CORINNE	FACILITY NUMBER: 304300905
	VISIT DATE: 07/10/2023

NARRATIVE

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Safe sleep consultation provided during today's inspection. Safe sleep 15-minute log, individual infant sleeping plan (LIC 9227), and PIN 20-24-CCP was provided during today’s inspection. LPA asked Licensee if she had any questions or concerns about Infant Safe Sleep regulations. Licensee had no questions or concerns at this time.

The facility was not in compliance and violation of the California Code of Regulations, Title 22, Division 12 were observed, discussed, and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today, Infant Safe Sleep, CCR 102425 (b)(1)A and CCR 102425(i) (see LIC 809D).

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.

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

Exit interview conducted and report was reviewed with the licensee Jacobo-Seguin, Corinne. A notice of site visit was given and must remain posted for 30 days. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC809 (FAS) - (06/04)

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