304313937-10-3-2024-06-CC-DVSA-D9PVBT-20241003161803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313937
Report Date: 10/03/2024
Date Signed: 10/03/2024 04:18:13 PM

Document Has Been Signed on 10/03/2024 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:	ACEVES, ANA		FACILITY NUMBER:	304313937
ADMINISTRATOR/ DIRECTOR:	ACEVES, ANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 499-6980
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 2	DATE:	10/03/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Licensee, Ana Aceves		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A 3yr. Required Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Dianna Valdez Santana met with licensee, Ana Aceves and census was taken. There were 2 children (1 preschool-age child and 1 infant) present at the time of the inspection being cared for by the licensee. 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. Currently there is 1 adult including the licensee living in the facility. Facility Day care hours are 12:30am-6:00pm, Monday through Sunday. 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 child safety gates. The childcare area consists of the living room, kitchen, dining room, napping room (bedroom #2) and one restroom. The children walk through the living room and through the main hallway to the bathroom. Licensee stated the children's primary area is the living room. The off-limit areas are bedroom #1. There are working carbon monoxide, smoke detector alarms, 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 inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. There is no fireplace or open-face heater present at the facility. The home has age-appropriate toys for the ages served. LPA verified there is a working telephone service, which is the licensee’s cellphone. Licensee stated they use the backyard area 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. Page 1 of 4.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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 10/03/2024 04:18 PM - It Cannot Be Edited

Created By: Dianna ValdezSantana On 10/03/2024 at 03:02 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: ACEVES, ANA	FACILITY NUMBER: 304313937
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(d)(1)

Infant Safe Sleep

The provider shall place infants up to 12 months of age on their backs for sleeping. This requirement shall not apply if the infant has a medical exemption from a licensed physician that allows for an alternative sleep position. The exemption shall be attached to the Individual Infant Sleeping Plan [LIC 9227 (3/20)] and contain the following criteria: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 2 infants did not recieive the LIC9227 form upon enrollment therefore the forms were missing in their 2 files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Licensee stated she will have the parents of the two infants complete the form even though they are now over 1 yr. old. Licensee will email or send LPA the completed forms and she understands that she must provide the LIC9227 upon enrollment for any children 0-12months of age. LPA provided licensee the LIC9227 form.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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:

Thuy Ho

LICENSING EVALUATOR NAME:

Dianna ValdezSantana

LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

Page: 2 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: ACEVES, ANA	FACILITY NUMBER: 304313937
	VISIT DATE: 10/03/2024

NARRATIVE

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The licensee had a current roster of children in care. 5 random children’s records were reviewed during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. LPA provided licensee with a Safe Sleep consult and reviewed and discussed LIC 9227 Individual Infant Sleeping Plan forms with licensee. The LIC 9227, Individual Sleeping Plan form was reviewed for compliance, 2 out 2 infants did not have the LIC9227 forms in their files. Licensee stated the facility has conducted any emergency drills within the past six months. Last drill conducted on 4/10/24.

The licensee’s Pediatric CPR/First Aid certification is EMSA approved, it expired 2/2025. 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’s assistant was not ready to be reviewed or within compliance.

During today’s inspection, Licensee’s Mandated Reporter Training Certificate was current and it expires 12/20/25. 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's expires 12/2025.

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

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

Page: 3 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: ACEVES, ANA	FACILITY NUMBER: 304313937
	VISIT DATE: 10/03/2024

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: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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: ACEVES, ANA	FACILITY NUMBER: 304313937
	VISIT DATE: 10/03/2024

NARRATIVE

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Based on LPA’s observations, interviews and record review, the following deficiency was observed, the licensee did not have the LIC9227 for the infants enrolled. The following violation was observed and is being cited: CCR 102425(d)(1) Infant Safe Sleep. Please 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 and Health and Safety Code of California at the time of the visit.

Exit interview conducted and report was reviewed with the licensee, Ana Aceves. 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. Report was translated in Spanish by LPA. End of Report.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

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