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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312729
Report Date: 06/07/2023
Date Signed: 06/07/2023 04:49:32 PM

Document Has Been Signed on 06/07/2023 04:49 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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GALVEZ, GLORIAFACILITY NUMBER:
304312729
ADMINISTRATOR:GLAVEZ, GLORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 566-4587
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92656
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
06/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Gloria GalvezTIME COMPLETED:
05:20 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Mrs. Bootorabi. Upon arrival, an Entrance Checklist (LIC 126) was provided to the licensee Gloria Galvez.
Census upon entry:
Infants: 3
Children Over Two: 9
Adults Working Directly with Children: 2
Other Adults: 1
The licensee was operating within the licensed capacity as specified on the license. The Facility Day care hours are 7 am- 5:30 PM, Monday through Friday.

During today’s inspection, LPA was greeted by licensee. Children were observed to be inside the living room.
Posted Requirements were reviewed during today's visit. Upon arrival, the LPA verified that the following documents were posted in a prominent, publicly accessible area; License, PUB 394 Notification of Parents’ Rights, and LIC 9148 Earthquake Preparedness. The items were not posted in a prominent public area that could easily accessible. The licensee was given a consultation to meet this requirement.

Facility Tour of the inside was conducted with the licensee. The LPA and licensee toured the facility inside and outside. The facility sketch (LIC 999) was verified. Areas stated to be off-limits by the facility sketch were made off limits by closed doors. The licensee was consulted on placing a baby sage gate between the laundry room and the bedrooms that are inaccessible to children.

Detergents, cleaning compounds, and other items that could pose a danger if readily available to children were not stored inaccessible to children in the bathroom and outdoor area (Clorox wipes). The kitchen locks were not functioning during inspection. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GALVEZ, GLORIA
FACILITY NUMBER: 304312729
VISIT DATE: 06/07/2023
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Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. The children's bathrooms are clean. Children nap on cots and cribs. Bedding used in cribs are washed by licensee on a weekly basis. Soiled blankets are washed by licensee at the home.

The licensee stated the children's primary care and play areas consist of the living room and front yard. The licensee stated that bedroom #1 is off limits as of now. Licensee was consulted on reporting requirements and a copy of the regulations was provided.

The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was somewhat maintained and not free of dangerous hazards to children. Licensee observed a container of Clorox wipes outside that were accessible to children. A consultation about the front yard was provided. The cushioning material used at the facility consists of artificial grass. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility.

Identify Location & Functioning of the carbon monoxide, smoke detector and fire extinguisher was reviewed and tested. The licensee tested both and both carbon and smoke were functioning. The fire extinguisher was marked in full.

Records Reviewed:The LPA requested to review the LIC 610A Emergency Disaster Plan, Verification of Disaster and Fire Drills, and LIC 9040 Facility Roster. The last drill was conducted on January 13, 2023 at 12:40 pm. The LPA provided consultation to support the licensee to meet the requirements at all times.

Personnel Record 2:26 pm:The LPA requested completed personnel records 2 of 2 adults working with children for review during today’s inspection. The following documents were reviewed in the files provided by the licensee; CPR First Aid Certification, LIC 9052, Immunization records, TB clearance and LIC 9108, and a Mandated Reporter Training Certificate. The licensee did not have a separate file for each individual or documents organized for review.

CPR & FIRST AID for 2 of 2 adults was taken on 06/17/2021 Mandated Reporter Training was last taken on June 1, 2022.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
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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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GALVEZ, GLORIA
FACILITY NUMBER: 304312729
VISIT DATE: 06/07/2023
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Children’s Records Reviewed at 2:35 pm:The LPA requested completed children’s records of children enrolled. Children's records were reviewed, and there was a separate, complete, and current record for each child. The LPA reviewed files to verify the following documents LIC 282 Affidavit Regarding Liability Insurance, Immunization Records, LIC 700 Identification and Emergency Medical Treatment, and LIC 995A Notification of Parents’ Rights.The licensee was not in compliance and a consultation was provided to support the licensee to meet compliance.

Individual Sleep Plans and Sleep Logs were request at 2:53 pm. The licensee did not have them available for review. LPA observed 3 infants from 0-24 months. An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and maintained at the facility in the infant’s file. LPA observed and reviewed LIC 9227 Individual Infant Sleeping Plan in children’s files of 0 of 3 infants.

A facility License File Review was request but not received by licensee. The LPA asked Licensee if there are any updates to be made for LIC 279,LIC 610, or LIC 999. Licensee stated there were changes to the facility and a facility sketch will be submitted. A consultation was provided due to being a large facility and removing a room could cause capacity change.

Incidental Medical Services (IMS) policy was discussed and the licensee stated she does not provide IMS currently in her FCCH. 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) Commonly Asked Questions American Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Know the Law About The Americans with Disabilities Act and Individuals with Disabilities Education Act https://rrnetwork.org/assets/general-files/Child-Care-Law-Center-ADA_IDEA_Housing-April-2019.pdf

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GALVEZ, GLORIA
FACILITY NUMBER: 304312729
VISIT DATE: 06/07/2023
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During today’s inspection, the licensee and LPA discussed the following:

- Stay up to date with LIC 9227 and discuss with parents any new changes

- Ensure 15 min checks are conducted & logged (The initial of the person checking should be included)


- 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.
- Always place infants on their backs to sleep
- 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 if 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.
The following are additional resources.
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
The American Academy of Pediatric https://www.aap.org/en/patient-care/safe-sleep/
Safe Sleep Regulations https://cdss.ca.gov/Portals/9/Additional-Resources/Legislation-and-Regulations/Public%20Hearing%20Docs/f031803RegulationsTextOALfinal.pdf

Background Checks :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 2 adults including the licensee and 0 minor child living in the facility. The licensee was reminded that any individuals 18 years or older must have a background check clearance. The licensee was also reminded that any children turning 18 years must obtain a background check to maintain compliance.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GALVEZ, GLORIA
FACILITY NUMBER: 304312729
VISIT DATE: 06/07/2023
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LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Video: https://ccld.childcarevideos.org/family-child-care-providers/background-check-requirements-for-caregivers/



CCLD website www.ccld.ca.gov was provided to licensees to access regulations, updates, and licensing forms.

The licensee was informed of the important updates available at www.ccld.ca.gov and may request to be added to an email list to receive Community Care Licensing Important Notifications from the above website and selecting Receive Important Updates: https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/child-care

Child Care Licensing Program Webinars: The Child Care Licensing Program is pleased to continue offering webinars to share important information with the child care licensing community in 2023.


2023 Webinar Schedule
• Tuesday, June 27, 2023, 6:00 p.m.
• Tuesday, September 26, 2023, 6:00 p.m.
• Tuesday, December 12, 2023, 6:00 p.m.
To register for webinars, see Provider Information Notice (PIN), PIN 22-30-CCP. Providers may wish to view previously recorded webinars.
• Child Care Licensing Program Provider Webinar (Nov/Dec 2022)
• Child Care Licensing Program Provider Webinar (October 2022)
• Child Care Licensing Program Provider Webinar (September 2022)
• Child Care Licensing Program Provider Webinar (August 2022)
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 5 of 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GALVEZ, GLORIA
FACILITY NUMBER: 304312729
VISIT DATE: 06/07/2023
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Children and Car Safety: Leaving infants or children unattended in a parked car can have disastrous consequences, as the temperature inside a vehicle can rise quickly, even with a cracked window. Before leaving a vehicle, it is crucial to double-check that everyone has exited and to check the backseat for any children who may have fallen asleep. To avoid forgetting a child in the car, caregivers can place a stuffed animal in the front seat as a reminder and best practice suggestion. Providers are reminded that you are responsible for the care and supervision of children during transportation regardless of the vehicle type (car or van). It is recommended that providers create, educate, and enforce policies and practices to ensure the safe transportation of children in care.

Heat Precautions in Child Care: Health and age play a significant role in how people react to extreme heat. Individuals at most significant risk for heat-related illness include infants and children up to four (4) years of age. By knowing how to prepare for a heat wave, and what to do when one occurs, you can avoid the biggest health dangers, such as heat exhaustion and heat stroke. Before sending children out to play, adequate supervision is required and staff need to know how to protect them against heat-related illness. Providers must meet the requirements of the applicable HSC, Child Day Care Act, Sections 1596.70 et seq., and California Code of Regulations, Title 22, Division 12. Have a safe, healthy, and enjoyable summer!

The licensee understands they 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 for 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.

The LPA provided a consultation today on:
High Chairs
Cribs
Supervision
Children Records
Diapering
Health & Safety
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 6 of 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GALVEZ, GLORIA
FACILITY NUMBER: 304312729
VISIT DATE: 06/07/2023
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The facility was not in compliance and violations 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: CCR 102417(g)(4),CCR 102425(a)(6), CCR 102425(j), CCR 102419(b), CCR 102421(b), CCR 102425(c), CCR102425(j)(2)(D),


Due to the Type A violations cited today, the licensee shall post, and provide copies, of the report to parents/guardians of the children in care at the facility by the next business day and shall provide them to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. In addition, the licensee shall immediately post upon receipt of the Proof of Correction for 30 consecutive days.

An exit interview was conducted with the licensee Gloria. 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 at the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.

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/inspection-process

End of Report.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 06/07/2023 04:49 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 06/07/2023 at 03:35 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: GALVEZ, GLORIA
FACILITY NUMBER: 304312729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, and interview, the licensee did not comply with the section cited above by means of having unlocked cabinets in the bathroom, and safety latches not working in the kitchen which poses an immediate health, safety or personal rights risk to persons in care. When LPA inspected the bathroom there were many hazardous items that can pose a danger to children.
POC Due Date: 06/14/2023
Plan of Correction
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The licensee stated that she will be removing the items and install magneted locked on the cabinets.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
Page: 8 of 14
Document Has Been Signed on 06/07/2023 04:49 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 06/07/2023 at 03:35 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: GALVEZ, GLORIA
FACILITY NUMBER: 304312729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)(6)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (6) Each infant's bedding shall be used for him/her only. Bedding that touches the infant’s skin shall be cleaned at least weekly or before use by another infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and interview with the licensee , the licensee did not comply with the section cited above due to children being observed and licesee stating children share the bedding in the two cribs observed in the living room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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The licensee stated once she cleans and organize bedroom #1 she had additional beds to avoid children from sharing
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, and interview, the licensee did not comply with the section cited above due to having blankets in the cribs when the licensee walked in to the home which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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The licensee stated one she opens bedroom #1 every child will have their own bed and crib.
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:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
Page: 9 of 14
Document Has Been Signed on 06/07/2023 04:49 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 06/07/2023 at 03:35 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: GALVEZ, GLORIA
FACILITY NUMBER: 304312729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, and record revie, the licensee did not comply with the section cited above by not providing proof of 15 min checks to LPA upon request during inspecgtion which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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The licensee stated she will have her sheets ready for her next inspection.
Type B
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, and interview the licensee did not comply with the section cited above due to not having the following documents in prominently accessible area to parent. The documents are behind the door on a shelve and cannot be seen when parents walk in which poses/posed a potential health, safety and personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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2
3
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The licensee stated she will be moving them
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:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
Page: 10 of 14
Document Has Been Signed on 06/07/2023 04:49 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 06/07/2023 at 03:35 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: GALVEZ, GLORIA
FACILITY NUMBER: 304312729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation and record review, the licensee did not comply with the section cited above in children's files which poses/posed a potential health, safety or personal rights risk to persons in care. The licensee did no have multiple documents in the childrens files completed or missing.
POC Due Date: 06/14/2023
Plan of Correction
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The licensee she will be working on her forms and reviewing all files to have them in order for her inspections.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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 by means of not having this document completed in the childrens files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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Moving forward the licensee will provide the document to parents enrolling children uner 12 months
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:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/07/2023 04:49 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 06/07/2023 at 03:35 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: GALVEZ, GLORIA
FACILITY NUMBER: 304312729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, and interview), the licensee did not comply with the section cited above by means of not using a room she converted into storage and not using which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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2
3
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The licensee stated she will be clearing it and organizing it by this weekend. The licensee stated she will send LPA a email of proof of correction.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
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