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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312903
Report Date: 05/03/2023
Date Signed: 05/03/2023 04:18:58 PM

Document Has Been Signed on 05/03/2023 04:18 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:CAMACHO, EVANGELINAFACILITY NUMBER:
304312903
ADMINISTRATOR:CAMACHO, EVANGELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 365-2500
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
05/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Evangelina Camacho, LicenseeTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) P Rivas conducted an unannounced annual inspection and met with Licensee, Evangelina Camacho and together conducted physical plant tour. Upon entrance LPA observed
one school age child, two infants and 7 pre school children . All but the school age child were napping. Also present was licensee's assistant. Hours of operation are Mon-Friday 8:00am to 6:00pm.

A review of the Facility Personnel Report Summary via Guardian was conducted on 05/03/2023 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The licensee, Ms. Camacho was reminded that all adults 18 and over, 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 family day 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.
During today’s inspection, LPA toured the inside and outside areas identified in the facility sketch as accessible to childcare children. The following was observed and reviewed during this inspection. This is a one-story home which consists of 4 bedrooms and 3 bathrooms. The rooms utilized for the day care are the living room , Bedroom #1 and #2, part of outside patio, one bathroom located next to bedrooms
There are no bodies of water on the premises. The Licensee was reminded that full supervision is required at all times to ensure children do not have access to the off-limit areas. The off-limit areas are kept closed during day care hours as stated by licensee.

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: CAMACHO, EVANGELINA
FACILITY NUMBER: 304312903
VISIT DATE: 05/03/2023
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There are working carbon monoxide, smoke detector 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. A technical violation under 102417 (g) (1) will be issued for Fire Extinguisher, it was more than one year old, purchased 10/21.
There are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. The facility has age appropriate toys for the ages served. LPA verified there is a cellular line.The licensee does have a current roster of children in care.
The licensee's Pediatric CPR/First Aid certification expires on 07/1/2023. 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. Two staff files reviewed had immunizations as required.
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. Licensee had certificate that expired In 10/22 in file. Licensee stated she took training in 2021 but no proof was in file. However, licensee was able to provide procedure and process for reporting abuse. A technical violation will be issued under H&S 1596.8662.

Incidental Medical Services (IMS) policy was discussed. States she does not have anyone on medication. For IMS information see PIN 22-02-CCP: Best Practices Related to the Provision of Incidental Medical Services in Child Care Centers and Family Child Care Homes. 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 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, immunizations, Pediatric CPR/First Aid, and mandated reporter training.CCLD website www.cdss.ca.gov

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CAMACHO, EVANGELINA
FACILITY NUMBER: 304312903
VISIT DATE: 05/03/2023
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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. “A Child Care Providers Guide to Safe Sleep” was discussed to the licensee.

The following electronic links were also provided: English: 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.aspx

NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative


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

LPA reviewed with licensees the following safe sleep best practices:
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 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.

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CAMACHO, EVANGELINA
FACILITY NUMBER: 304312903
VISIT DATE: 05/03/2023
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In the areas that were evaluated, The following deficiencies were observed under the

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.



An exit interview was conducted with licensee, in Spanish with Evangelina Camacho. 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. 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.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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Document Has Been Signed on 05/03/2023 04:18 PM - It Cannot Be Edited


Created By: Pat Rivas On 05/03/2023 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: CAMACHO, EVANGELINA
FACILITY NUMBER: 304312903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023

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, LPA viewed two infants in play yard with blankets, picture was taken, Licensee also stated that she was aware of rule but the two infants have a difficult time falling asleep without a blanket, the licensee did not comply with the section cited above in 2 out of 2 infants sleeping in playyard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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LIcensee immediately removed blankets from two yards, licensee will submit statement that she understand regulations and sign a statement to that effect, licensee will training in safe sleep regulations. Licensee will provide sign in sheet for training. copies can be emailed to LPA at patricia.rivas@dss.ca.gov
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:Rina Lopez
LICENSING EVALUATOR NAME:Pat Rivas
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


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