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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844177
Report Date: 05/11/2022
Date Signed: 05/11/2022 06:11:13 PM

Document Has Been Signed on 05/11/2022 06:11 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:PINEDA FAMILY CHILD CAREFACILITY NUMBER:
334844177
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 13DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Eva Pineda, LicenseeTIME COMPLETED:
06:15 PM
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On 05/11/2022 at 10:18 AM Licensing Program Analyst (LPA) Susan Brewer, arrived at the facility unannounced to conduct an annual inspection. LPA conducted a COVID-19 survey and was granted entry by Licensee Eva Pineda. LPA toured the facility inside and out, reviewed records, and observed and/or discussed the following: Present were 13 children, 6 infants under 2 years old and 7 children ranging in ages 2-4 years old, Staff 1 cleared, staff 2 uncleared and 1 resident adult uncleared or fingerprinted. Staff 1 exited the facility at 11:45 AM.

Normal days and hours of operation are Monday- Friday, 6:00 AM to 6:00 PM OFF-LIMIT AREAS INCLUDE: Garage, Entire 2nd Floor, Kitchen Pantry, West side fence in the backyard and Pool.

The inspection consisted of reviews of the following domain: Physical Plant, Care and Supervision, Records, Facility Administration, Staffing Ratio and Capacity, Personal Rights. The inspection found the facility to be in compliance in these domains, except as noted on the LIC809D. Deficiencies cited this visit were 3 Type A deficiencies for 102370(d)(1) Criminal Record Clearance, 102416.5(a) and 102416.5(d) Staffing Ratio & Capacity.

· The facility is NOT operating within the licensed capacity and appropriate ratios, at 10:18 AM LPA arrived and observed the Licensee Eva Pineda operating over capacity and out of ratio with 13 children present, 6 infants under age 2 years old and 7 children ages of 2-4 years old.


· The Licensee is present in the home and has ensured that children in care are supervised with 1 qualified assistant, howver Staff 2 or #3 listed on the LIC859 Confidential Names form is an uncleared adult. There is 1 adult resident #4 listed on LIC859 form that is not cleared on 05/11/2022.
· When temporarily absent from the home, the Licensee shall arrange for a substitute adult to care for and supervise children.
· A working telephone is present.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PINEDA FAMILY CHILD CARE
FACILITY NUMBER: 334844177
VISIT DATE: 05/11/2022
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· Appropriate fire extinguisher, smoke detector and carbon monoxide detector are present and were tested by the Licensee Eva Pineda during this inspection 05/11/2022.
· All hazardous items are inaccessible, this includes detergents, cleaning compounds, medications and other items which could pose a danger to children, however Licensee will check for recalls on infant equipment.
· Storage of poisons is inaccessible to children and locked
· There is a properly barricaded fireplace on 05/11/2022
· No guns or weapons present as stated by the Licensee Eva Pineda. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 regulations.
· Stairs are barricaded 05/11/2022.
· Home is clean and orderly, with heating and ventilation for safety and comfort.
· Safe and appropriate toys and equipment are present for both indoor and outdoor activities.
· Outdoor play areas are fenced and or appropriate supervision is NOT present, as the licensee was operating with 13 children, 6 children being infants under age 2 years old, when qualified staff exited facility.
· Verification of control of property on file and verified by tax bill.
· Pediatric CPR and First Aid, completed on 01/11/2020 Card expired on 01/2022
· Health & Safety Certificate - completed on 08/26/2016 Mandated reporter: General: NOT ON FILE AB1207 Child Care Specific Expires: NOT ON FILE
· Fire clearance: NOT ON FILE Documentation of fire & earthquake drills to be conducted every six months: Last Fire and Earthquake Drill conducted on 08/19/2021 at 10:00 AM, with 4 children present and lasted 10 minutes.
· There ARE bodies of water, 05/11/2022. Licensee Eva Pineda 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.
· Clean, safe and age appropriate toys
· Children’s files are NOT complete on 05/11/2022 for daycare children listed on the 857 Confidential Names List, where 2 of 6 infants present and in care were missing entire enrollment packets, 6 infants were missing Safe Sleep Logs, 4 children missing immunization records, 2 children missing parent rights forms.
· Staff’s files are NOT complete on 05/11/2022, LPA S. Brewer, conducted a review of staff records and Staff 1 is missing Measles, Pertussis, Influenza, LIC9108, LIC9052 and Mandated Reporter Training Certificates. The licensee failed to maintain a file for Staff 2, no records on file.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PINEDA FAMILY CHILD CARE
FACILITY NUMBER: 334844177
VISIT DATE: 05/11/2022
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· To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication of Epinephren pen, which was stored in a lunch bag with the daycare child’s belongings and equipment/supplies, and reviewed children’s, personnel, and administrative records which did not meet Title 22 regulation as there was not a prescription or plan on file to document the child’s information or physicians instruction for dispensing in the event of an emergency. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 For FCCHs: Incidental Medical Services (IMS) policy was discussed.

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 Eva Pineda, 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.

LPA Susan Brewer, discussed the safe sleep regulations with licensee Eva Pineda 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.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PINEDA FAMILY CHILD CARE
FACILITY NUMBER: 334844177
VISIT DATE: 05/11/2022
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Plan of Correction:

1. Live Scan receipts for Two Uncleared adults residing and working at the Family Child Care home on or before, LIC508 Criminal Record Clearance, Copy of valid photo ID, proof of TB screening.

2. Staff 1 and 2: Proof of Measles, Pertussis and Influenza or letter to decline, the close of business day 05/30/2022,


3. Staff 1 and 2: LIC9108 Statement Acknowledging the responsibility to report child abuse; Proof of Mandated Reporter Training for General and AB1207 Child Care specific by 05/30/2022
4. Licensee Eva Pineda: CPR/1ST Aid Training and Mandated Reporter Training for General and AB1207 Child Care Specific on or before 05/30/2022.
5. LIC279 Application form with updated information to include adult residents, contact numbers, etc., Should the licensee decide they would like to begin the process for increase of capacity, check the appropriate box and include the application fee of $25.00 with submission of the LIC279 application form and LIC9054 Fire inspection request.
6. Incident Medical Services Plan (IMS) on or before 05/20/2022.
7. Updated LIC610 Emergency Plan.

Appeal rights discussed and a copy of this report was provided to the licensee Eva Pineda on this 05/11/2022.

A Civil Penalty has been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

LPA Susan Brewer informed licensee Eva Pineda that this report dated 05/11/2022 documents 3 Type A citations which shall be posted for 30 consecutive days as there is/are immediate risks to the health, safety, or personal rights of children in care.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PINEDA FAMILY CHILD CARE
FACILITY NUMBER: 334844177
VISIT DATE: 05/11/2022
NARRATIVE
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LPA Susan Brewer informed the licensee Eva Pineda, to provide a copy of this licensing report dated 05/11/2022 that documents any Type A citations to parents and/or guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Eva Pineda.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/11/2022 06:11 PM - It Cannot Be Edited


Created By: Susan Brewer On 05/11/2022 at 04:06 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: PINEDA FAMILY CHILD CARE
FACILITY NUMBER: 334844177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Susan Brewer's observation & review of facility records the licensee Eva Pineda did not comply with the section cited above, where Individual listed as #3 & #4 on LIC859 Confidential Names List, did not obtain Criminal Record Clearance for Individual #4 Cassidy Pineda DOB: 03/20/2001, turned 18 on 03/20/2019; Staff 2 or Individual #3 Cecilia De La Cruz, DOB: 05/06/1971 present & employed on 01/01/2022, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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The licensee Eva Pineda, agrees to have Individuals #3 and #4 listed on LIC859 Confidential Names List, complete Criminal Record Clearance & Fingerprinting on or before 05/12/2022, and submit proof of fingerpriting to Community Care Licensing. The licensee agrees to write a statement of understanding the Title 22 Regulation regarding Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility and submit on 05/12/2022.
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Susan Brewer's Observation and record review, the Licensee Eva Pineda, did not comply with the section cited above where 13 children present, are 6 infants listed on as #1-6 on LIC857 Confidential names list are under age 2 years old and 7 children present #7-13 on LIC857 are ages 2-4 years old, placing the faciilty out of Ratio, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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The licensee Eva Pineda, agrees not to operate over the licensed capacity and ratio. The licensee Eva Pineda, agrees to write a statement of understanding the Title 22 regulation 102416.5(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time, and submit the statement to Community Care Licensing by mail, fax or e-mail on or before 05/12/2022.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 05/11/2022 06:11 PM - It Cannot Be Edited


Created By: Susan Brewer On 05/11/2022 at 04:06 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: PINEDA FAMILY CHILD CARE
FACILITY NUMBER: 334844177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(c)
Staffing Ratio and Capacity
(c) The total licensed capacity for a Small Family Child Care Home shall not exceed eight children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Susan Brewer's Observation and record review, the licensee Licensee Eva Pineda, did not comply with the section cited above in 13 children present, are 6 infants listed on as #1-6 on LIC857 Confidential names list are under age 2 years old and 7 children present #7-13 on LIC857 are ages 2-4 years old, placing the facility over capacity, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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The licensee Eva Pineda, agrees to comply with Title 22 regulation and not operate over capacity and agrees to write a statement of understanding Title 22 regulation 102416.5(c) The total licensed capacity for a Small Family Child Care Home shall not exceed eight children, the statement will be submitted on or before 05/12/2022, by mail, fax or e-mail.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


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