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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312144
Report Date: 03/26/2024
Date Signed: 03/26/2024 04:34:38 PM

Document Has Been Signed on 03/26/2024 04:34 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:LOPEZ, MARTHA D.FACILITY NUMBER:
304312144
ADMINISTRATOR:LOPEZ, MARTHA D.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 543-4922
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
03/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee, Martha D. LopezTIME COMPLETED:
04:45 PM
NARRATIVE
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A 3yr. Required Random inspection was conducted at the facility by Licensing Program Analysts (LPAs) D. Valdez Santana and A. Castro met with licensee, Martha D. Lopez and census was taken. There were 5 children (3 preschool-age and 2 school-age) children in care. Licensee 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. Facility Day care hours are 6:30am-5:30pm, Monday through Friday.

During today’s inspection, LPAs and licensee 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 locked doors and child safety gates. The childcare area consists of the living room and one restroom. The children walk through the living room and through the master bedroom door to the bathroom. Licensee stated the children's primary area is the living room. There are working carbon monoxide, smoke detector alarm, 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 accessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. The facility has central A/C and heat. The home has age-appropriate toys for the ages served. LPAs verified there is a working telephone service, which is the licensee’s cellphone. Licensee stated they do occasionally use the outdoor areas for outside play. There were no poisons or other items observed which could pose a danger to children. There are no bodies of water on the premises. There is an empty water fountain filled with rocks in a sectioned off gated area of the back yard.
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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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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Document Has Been Signed on 03/26/2024 04:34 PM - It Cannot Be Edited


Created By: Dianna ValdezSantana On 03/26/2024 at 03:34 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LOPEZ, MARTHA D.
FACILITY NUMBER: 304312144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in an emergency drill was not conducted in the last six months, the last drill was conducted on 4/30/2023, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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Licensee, will email/send LPA Valdez Santana proof of documented emergency drill by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Thuy Ho
LICENSING EVALUATOR NAME:Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024


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: LOPEZ, MARTHA D.
FACILITY NUMBER: 304312144
VISIT DATE: 03/26/2024
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The licensee had a current roster of children in care. Five children files were reviewed and found to be in compliance. LPAs provided licensee with a Safe Sleep consult and reviewed and discussed LIC 9227 Individual Infant Sleeping Plan forms with licensee. The licensee’s Pediatric CPR/First Aid certification is current and expires 07/2025.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee was ready to be reviewed and within compliance.

During today’s inspection, Licensee’s Mandated Reporter Training Certificate was current and it expired 07/31/2024. 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.


Incidental Medical Services (IMS) policy was discussed and licensee stated she is not currently administering medication. 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


The licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left 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's, Pediatric CPR/First Aid, and mandated reporter training.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
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: LOPEZ, MARTHA D.
FACILITY NUMBER: 304312144
VISIT DATE: 03/26/2024
NARRATIVE
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CCLD website www.ccld.ca.gov 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 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.

Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf



AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspxNIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

· Always place infants on their backs for sleeping.


· Use only a tight-fitting sheet on the crib or play yard mattress.
· Do not hang any items from the crib or above the crib.
· Keep all items, including blankets, out of the crib or play yard.
· Pacifiers may be used as long as they do not have items attached to them.
· Infants should not be swaddled or have any items covering them while sleeping.
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.
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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: LOPEZ, MARTHA D.
FACILITY NUMBER: 304312144
VISIT DATE: 03/26/2024
NARRATIVE
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Safe sleep consultation provided during today's inspection. Safe sleep 15-minute log for infant present reviewed during today's consultation. LPA Valdez Santana asked Licensee if she had any questions or concerns about Infant Safe Sleep regulations 102425. A review of this regulation was provided to Licensee.

Based on LPAs’ observations, licensee last conducted a fire drill on 4/30/23 and has not conducted an emergency drill in the last six months. Licensee did not have a signed LIC 9108 form ready for Department review accessible to children in care. The following violation was observed and is being cited, CCR 102417(g)(9)(A) Operation of A Family Child Care Home, see attached LIC 809D.

In the areas that were evaluated, 1 Type B deficiency was observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Exit interview conducted and report was reviewed with the licensee, Martha D. Lopez. Appeal Rights and were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) 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.

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.

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.

Page 4 of 4. End of Report.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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