<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842838
Report Date: 01/13/2022
Date Signed: 01/13/2022 01:57:46 PM

Document Has Been Signed on 01/13/2022 01:57 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:TRUJILLO FAMILY CHILD CAREFACILITY NUMBER:
334842838
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
01/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Rosa TrujilloTIME COMPLETED:
02:15 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
On 01/13/2022 at 10:20 a.m., Licensing Program Analysts (LPAs) Blanca Ruiz and Destinee Hogue arrived at the facility to conduct a required annual inspection. Licensee has requested a capacity increase. A fire clearance for a capacity of 14 children was obtained and approved on 12/21/2021. Present during this inspection was Licensee, Rosa Trujillo and Licensee's spouse, Manuel Trujillo. This inspection was conducted in Spanish per licensee's request.
LPA toured the facility, inside and out, records were reviewed, and the following was observed and discussed with Licensee:
Normal days and hours of operation are: Monday-Saturday 6:00 a.m.-6:00 p.m. Saturday and Sunday
6:00 p.m. to 8:00 a.m.
OFF-LIMIT AREAS INCLUDE: Master bedroom, Bedroom #1 and Office room
- No bodies of water observed at the time of this inspection. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
- Licensee understands all guns, weapons and ammunition must be key-locked separately and made inaccessible per Title 22 regulations. - Storage areas for poisons are observed to be inaccessible and stored behind key-locked garage.
- All hazardous items are inaccessible, this includes; detergents, cleaning compounds, medications, and other items.
- There is a properly barricaded fire place
- Appropriate fire extinguisher, smoke detector and carbon monoxide detector are present and were tested by the applicant during this inspection.
- Home is clean and orderly, with heating and ventilation for safety and comfort
- Facility is a single-story residence
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: TRUJILLO FAMILY CHILD CARE
FACILITY NUMBER: 334842838
VISIT DATE: 01/13/2022
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
26
27
28
29
30
31
32
- A working telephone is present.
- Outdoor play areas are fenced, and appropriate supervision was observed at the time of this inspection.
- The facility is operating within the licensed capacity and appropriate ratios were observed at the time of this inspection.
- The Department shall notify a Licensee to immediately terminate the employment of, or to remove/bar any person with specified convictions or for other reasons. The Licensee shall comply with the notice.
- Criminal record clearances are required prior to all adults living or working in a Family Child Care Home. A civil penalty of $100.00 per day the person has been present, may be assessed. All individuals subject to a criminal record review shall obtain a criminal record clearance or exemption prior to working, residing or volunteering in a licensed home. This was verified on 01/13/2022.

Facility Records Review:
- Each child’s file contains a copy of the emergency information card with required information
- Pediatric CPR and First Aid Card expires on 09/2023
- AB 1207 Mandated Child Abuse Reporter Training- Document not available for review
- Documentation of emergency disaster drills on file. Emergency disaster drill completed on 12/21/2022
- Review of staff records contain proof staff are immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year or provide a statement denying the influenza vaccination.

- 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

- Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child 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.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: TRUJILLO FAMILY CHILD CARE
FACILITY NUMBER: 334842838
VISIT DATE: 01/13/2022
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
26
27
28
29
30
31
32
 The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

- The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

- The Duty Officer is available to answer questions Monday – Friday from 8:00am to 5:00pm at (951)782-4200.

NEW Safe Sleep Regulations (Effective September 15, 2020):
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.

- 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.

See LIC809D for cited deficiencies.

Once all corrections have been verified, the application for a increase of capacity will be submitted for approval with a maximum capacity of 14 children. Licensee was advised that all corrections are due within 30 days or the application may be withdrawn.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.



Exit interview conducted and report was reviewed with the Licensee, Rosa Trujillo.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/13/2022 01:57 PM - It Cannot Be Edited


Created By: Blanca Ruiz-Silva On 01/13/2022 at 12:59 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: TRUJILLO FAMILY CHILD CARE
FACILITY NUMBER: 334842838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Licensee and licensee's assistant 's Mandated Reported Certificates were not available for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2022
Plan of Correction
1
2
3
4
Licensee agree to provide Mandated Reported Certificates by 01/27/2022.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in licensee's assistant immunization records missing TDAP and Flu or statement declining Flu vaccine which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2022
Plan of Correction
1
2
3
4
Licensee agree to provide proof of immunization for assistant to Community Care Licensing by 02/13/2021
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:Aaron Ross
LICENSING EVALUATOR NAME:Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/13/2022 01:57 PM - It Cannot Be Edited


Created By: Blanca Ruiz-Silva On 01/13/2022 at 12:59 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: TRUJILLO FAMILY CHILD CARE
FACILITY NUMBER: 334842838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above licensee did not have LIC 9052 for licensee's spouse/ assistant for review during LPA's inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2022
Plan of Correction
1
2
3
4
Licensee agrees to provided copy of LIC 9052 to Community Care Licensing by 01/20/2022.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in C3 Immunization records were not available for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2022
Plan of Correction
1
2
3
4
Licensee agrees to provided copy of immunization records to Community Care Licensing by 02/13/2022.
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:Aaron Ross
LICENSING EVALUATOR NAME:Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6