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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313937
Report Date: 05/09/2023
Date Signed: 05/09/2023 10:05:49 AM

Document Has Been Signed on 05/09/2023 10:05 AM - 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, ANAFACILITY NUMBER:
304313937
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 9CENSUS: 4DATE:
05/09/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ana Aceves, LicenseeTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Stacy Torrence conducted a case management inspection, in response to licensee’s request for a capacity increase. LPA met with licensee Ana Aceves, who guided analyst on a tour of the facility. LPA Torrence observed four children in the designated daycare area. The facility was within licensed capacity and the required ratio. Licensee stated there is currently one adult and no minor children living in the home. Licensee stated she is not currently registered with any Foster Care agency or holds a foster parent license. Licensee was reminded if changes to notify the licensing office.
A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

This is a single-story home with two bedrooms, one bathroom, living room, kitchen, dining room, laundry area, front yard (not fences), and backyard (fenced). Licensee has designated one bedroom, one bathroom, living room, kitchen, dining room, and backyard as part of the day-care. Licensee has designated one bedroom and one bathroom, as the off-limit areas. Licensee has a child proof safety gate at the entrance leading to the bedroom and bathroom, ensuring these areas are inaccessible to the children in care. The licensee 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 licensee has a cell phone that is used for childcare. The licensee was informed if a cell phone is used for childcare, it must remain on the premises at all times during hours of operation. Licensee was informed and understands the home is to be free from smoking during hours of operation.
The facility has a wall heater, located in the hallway, which is barricaded by a child proof safety gate. There are no fireplaces in the home. Cleaning solutions/chemicals, utensils, and sharp knives located in the kitchen, locked in a cabinet above the countertop. Poisons/Hazardous items are not stored on site, and none were observed. There are no bodies of water. 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. Licensee 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.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ACEVES, ANA
FACILITY NUMBER: 304313937
VISIT DATE: 05/09/2023
NARRATIVE
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Licensee will use the backyard for children's outdoor activities. The back yard is appropriately fenced. LPA observed play equipment to be safe and free of hazards.

Per licensee, she will provide breakfast, lunch, and snacks for the children. LPA reminded applicant, that if food is not provided and food is brought from the children’s homes; container shall be labeled with child’s name and properly stored or refrigerated. Per licensee, all children will nap in the bedroom. Licensee stated parents will provide linen and blanket for the children.



Licensee’s Mandated Reporter Training were current. EMSA approved Pediatric CPR and Pediatric First Aid was current for licensee, which expires on 02/25.

The licensee does have a current roster of children in care. Children’s records for children present during LPA’s inspection were reviewed and it was discovered that C#4 file did not have proof of immunizations.



LPA advised the licensee how to access forms, regulations and quarterly updates online at: www.ccld.ca.gov.

LPA consulted and explained Child Abuse Reporting, Updated Parent’s Rights Poster with Complaint Hotline information, Never Shake a Baby, Sudden Infant Death Syndrome (SIDS), and Safe Sleeping practices.

Fire clearance granted on 04/21/2023.

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 violation of the California Code of Regulations, Title 22; Division 12, was observed and cited today: 102418(a)-Immunizations (see LIC 809D).

A new license for operating a Large Family Child Care Home shall be issued upon final review and if additional information is needed, licensee shall be contacted.

An exit interview was conducted. The report was reviewed and discussed with licensee. 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. The Notice of Site Visit must be posted on or adjacent to the door. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2023 10:05 AM - It Cannot Be Edited


Created By: Stacy Torrence On 05/09/2023 at 09:17 AM
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: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2023
Section Cited
CCR
102418(a)

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102418(a) Immunizations. Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17. This requirement is not met by: After LPA review of children's records, it was discover that C#4 file did not have proof of
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Per licensee, she will email proof of C#4's immunization records to LPA by POC due date of 05/11/2023.
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required immunizations records. This poses a potential risk to the children in care.
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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:Thuy Ho
LICENSING EVALUATOR NAME:Stacy Torrence
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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