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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313925
Report Date: 09/01/2021
Date Signed: 09/01/2021 01:19:42 PM

Document Has Been Signed on 09/01/2021 01:19 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:VELASCO, YADIRAFACILITY NUMBER:
304313925
ADMINISTRATOR:VELASCO, YADIRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 393-7250
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/01/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Yadira Velasco, ApplicantTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Stacy Torrence conducted a pre-licensing inspection of the facility on today’s date due to receiving an application on 07/15/2021 requesting a location change. Applicant has requested to relocate her family childcare from 1022 Carlton Place, Santa Ana to 9 Bennington, Irvine. LPA toured the facility, with Yadira Velasco, applicant. Currently there are four adult residents and two minor children living in the home. Applicant stated she is not registered with any Foster Care agency or holds a foster parent license. Applicant was reminded if changes to notify the licensing office.

A review of criminal clearance records on this date indicates adults who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The facility is a two-story home with five bedrooms (four bedrooms located upstairs), three bathrooms (two bathrooms upstairs), living room, family room, kitchen, dining room, laundry room, attached garage, front yard (not fenced), and backyard (fenced). Applicant has designated the family room, kitchen, one bathroom (located downstairs), and backyard as part of the daycare. Applicant has designated the five bedrooms, two bathrooms, living room, dining room, laundry room, front yard, and attached garage, as the off-limit areas. Applicant has placed child proof safety gates at both entrances of the kitchen, ensuring the off-limit areas are inaccessible to child in care. Applicant has placed child proof safety knob on the downstairs bedroom. Applicant has a child proof safety knob and dead bolt lock on the garage door. Applicant has placed a safety gate at the bottom of the stairs leading to the second floor. The applicant acknowledged the children may never enter the off-limit areas, during operation hours. Control of property was verified by LPA during today’s inspection. The applicant has a cell phone, in which is used for the daycare. The applicant was informed if a cell phone is used for childcare, it must remain on the premises at all times during hours of operation. Applicant was informed and understands the home is to be free from smoking during hours of operation.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: VELASCO, YADIRA
FACILITY NUMBER: 304313925
VISIT DATE: 09/01/2021
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The facility has two fireplaces. One located in the family room, barricade by a free-standing screen and a bookshelf and the other fireplace located in the master bedroom, which is designated as one of the off limit areas. Cleaning solutions/chemicals, utensils, and sharp knives located in the kitchen are all inaccessible, by placing them in cabinets above the kitchen counters. Applicant has also placed child proof safety latches on the kitchen drawers that required them. Poisons/Hazardous items are not stored on site, and none were observed. There are no bodies of waters on the premises. The toys are age appropriate and in good condition for the potential ages served. Baby walkers, bouncers, jumpers, and similar items will not be used for children in care. The applicant stated there are no weapons or firearms on the premises. When firearms are present, they must be locked and stored separately from the ammunition. During today's inspection, the smoke detector and carbon monoxide were operable, and the fire extinguisher was charged.

EMSA approved Pediatric CPR and Pediatric First Aide are current for the applicant and assistant, which expires on 08/2023. Applicant has completed the Preventative Health training. Applicant has completed the Lead Poisoning Prevention Course on 08/2021.

Incidental Medical Services (IMS) policy was discussed. 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 following was discussed with applicant: Individuals who are 18 years of age or older living or working in the home must be fingerprinted cleared prior to being present in the facility. LPA provide applicant with website for Live-Scan locations oag.ca.gov/fingerprints/locations for all adult complete LIC 9163. If adult is fingerprinted cleared and associated to another facility, licensee must submit a Criminal Record Transfer Request (LIC 9182) or Exemption Transfer Request form (LIC 9188). Contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182 or LIC 9188) with copy of a valid identification issued by State or Federal Government and Criminal Record Statement (LIC 508) to fax # (714)703-2831 prior to hiring adult. Failure to complete the clearance process or license association for any adult resident or assistant will result in a civil penalty assessment against the license.




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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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: VELASCO, YADIRA
FACILITY NUMBER: 304313925
VISIT DATE: 09/01/2021
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LPA reviewed Unusual Incident Report (UIR) form (LIC 624B)-advised to contact Licensing Officer of the Day within 24 hours and complete the UIR within seven days by faxing LIC624B to (714)703-2831. LPA advised applicant to report to licensing any unusual incident or child absence that threatens the physical or emotional health or safety of any child or any changes to hours and days of operation and also for any changes to facility, including on/off limit areas and change in phone number.

LPA reviewed with applicant requirements of Disaster Preparedness drills (documented every 6 months). The LPA advised of Affidavit Regarding Liability Insurance (LIC 282) if did not purchase liability insurance and to maintain the form in the children's files, and Car Safety Seat pamphlet were discussed and provided to the applicant. Posting requirements which include but not limited to Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9141), Parents Rights (PUB 394), Notice of Site Visit (LIC 9213), and License (LIC 203). LPA reviewed with applicant the need to maintain records including but not limited to Children records and Staff/Adults records, (LIC 311D).

Applicant was informed of Mandated Reporter Training for self and all assistants. Department web site form was given to download forms, Title 22 regulations, and trainings on-line at http://www.ccld.ca.gov. The applicant was also informed to visit the website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.

LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

A copy of “A Child Care Providers Guild to Safe Sleep” was provided to applicant:


English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
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.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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: VELASCO, YADIRA
FACILITY NUMBER: 304313925
VISIT DATE: 09/01/2021
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LPA reviewed with applicant 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 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

Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf.

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian.


The facility was in compliance for a Large Family Child Care Home with Title 22 Regulations at the time of inspection. A license will be issued after final review, in the event additional requirements are needed, the applicant will be notified.

An exit interview conducted where the report was reviewed with the applicant. Appeal Rights and the appeal rights process was discussed with the applicant. The applicant was informed all appeals must be in writing and received by the licensing office within 15 business days. 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.

End of Report

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC809 (FAS) - (06/04)
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