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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312144
Report Date: 01/15/2026
Date Signed: 01/15/2026 04:31:45 PM

Document Has Been Signed on 01/15/2026 04:31 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:LOPEZ, MARTHA D.FACILITY NUMBER:
304312144
ADMINISTRATOR/
DIRECTOR:		LOPEZ, MARTHA D.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 543-4922
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
01/15/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Licensee, Martha D. Lopez TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 01/15/2026, Licensing Program Analyst (LPA), D.Valdez Santana conducted an onsite inspection for the purpose of a random annual Inspection. LPA was met by Licensee, Martha D. Lopez, LPA was provided a tour of the facility inside and outside. LPA observed licensee caring for 3 children (2 infants and one preschool-age child) Later at approximately 2: 25pm, one school-age child arrive to the facility. 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, LPA 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 (first door on the left). 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. LPA verified there is a working telephone service, which is the licensee’s cellphone. Page 1 of 4.
NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/15/2026 04:31 PM - It Cannot Be Edited


Created By: Dianna ValdezSantana On 01/15/2026 at 03:14 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: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
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:
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 LPA obsevered one infant child sleeping inside a playyard with a pillow and blanket inside which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2026
Plan of Correction
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Licensee immediately removed the pillow and blanket from the child's playyard and stated she will no longer put loose articles/objects in the playyards.
Type B
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

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 LPA observed one blanket hanging on one side of the playyard. LPA also observed a pocket attached to a side of the playyard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2026
Plan of Correction
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Licensee immediately removed the blanket and pocket from the child's playyard and stated she will no longer hang anything on the side of the playyard and will not have anything attached to the side of the playyard.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tina Nguyen
NAME OF LICENSING PROGRAM MANAGER:
Dianna ValdezSantana
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: LOPEZ, MARTHA D.
FACILITY NUMBER: 304312144
VISIT DATE: 01/15/2026
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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. There is one small pet dog and one pet dwarf hamster in the facility.

The licensee had a current roster of children in care. Four children’s files were reviewed and found to be in compliance. LPA reviewed Safe Sleep Regulations with Licensee. LPA observed the two infants had the LIC9227 and 15-minute log in their files. The licensee’s EMSA Pediatric CPR/First Aid certification is current and expires 08/2027.

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 expires 07/29/2026. 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. Page 2 of 4

NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: LOPEZ, MARTHA D.
FACILITY NUMBER: 304312144
VISIT DATE: 01/15/2026
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. Https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.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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NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: LOPEZ, MARTHA D.
FACILITY NUMBER: 304312144
VISIT DATE: 01/15/2026
NARRATIVE
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Based on LPA's observations, licensee last conducted a fire drill on 10/10/25 and has conducted an emergency drill within the last six months. LPA observed one infant sleeping in a playyard with a small pillow and blanket. LPA also observed a blanket hanging on one side of playyard and one pocket attached to another side of the playyard. Licensee immediately removed items after LPA reviewed the Regulations with Licensee.

In the areas that were evaluated, 2 Type B deficiencies, CCR 102425(b)- Infant Safe Sleep and CCR 102425(b)(3)- Infant Safe Sleep was observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. See attached 809D for deficiencies.


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. During the exit interview, the Licensee Martha D. Lopez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Report was translated in Spanish by LPA.

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.

NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
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