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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844177
Report Date: 05/02/2023
Date Signed: 05/02/2023 05:36:13 PM

Document Has Been Signed on 05/02/2023 05:36 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
RIVERSIDE SOUTH EAST, 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: 11CENSUS: 10DATE:
05/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Eva PinedaTIME COMPLETED:
06:00 PM
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On May 2, 2023, Licensing Program Analyst (LPA) William Chancellor arrived at the facility to conduct an annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:

· Normal days and hours of operation are: Monday to Friday 6am-6pm.

· Off-limit areas include: Entire upstairs, garage, kitchen pantry, entire pool area which is properly gated and west side yard, which is properly gated.

· The facility is licensed to have no more than 8 children as a small FCCH and is not operating within the licensed capacity and appropriate ratios. Present were 10 children, 11 are enrolled with two adults.


· Appropriate supervision was provided during this inspection

· A working telephone is present, and the current phone number is on file

· A fully charged fire extinguisher (2A:10BC) was observed. A smoke detector and carbon monoxide detector were present and tested by the Licensee during this inspection.

· Fireplace is properly screened to prevent access by children

· All hazardous items are stored inaccessible to children

· Toxins are locked

· Weapons are not present/stored according to Title 22. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

· Stairs are barricaded

· Clean, safe and age appropriate toys

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2023
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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PINEDA FAMILY CHILD CARE
FACILITY NUMBER: 334844177
VISIT DATE: 05/02/2023
NARRATIVE
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· Current roster is not updated.

· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted

· Documentation of fire and disaster drills on file – Last drill conducted 11/7/22. Licensee agrees to conduct fire/earthquake drill tomorrow because it has been within 6 months.

· There is a pool in the backyard that is properly gated and locked. 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.

· Verification of control of property on file

· Children’s records are incomplete

· Employee’s records are incomplete

· Mandated Reporter Training was not available for review during inspection.

· Pediatric CPR and First Aid Card expire in May, 2024.

· Health & Safety Certificate has been completed.


· Resident and/or staff records were reviewed and all adults who require caregiver background checks have received all required clearances and/or exemptions.

The licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

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
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023
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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PINEDA FAMILY CHILD CARE
FACILITY NUMBER: 334844177
VISIT DATE: 05/02/2023
NARRATIVE
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The Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov

The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.ca.gov

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.

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.

Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.



The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.

See LIC809-D for cited deficiencies

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.

An exit interview was conducted, and this report was reviewed with the licensee Eva Pineda. Appeal rights were discussed and provided during the exit interview.



A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/02/2023 05:36 PM - It Cannot Be Edited


Created By: William M Chancellor Jr. On 05/02/2023 at 04:20 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: 05/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above where child 6 had a tummy time toy inside the crib while asllep. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Licensee agrees to remove tummy time toy while child is asleep in play-yard and send a photo to LPA Chancellor. Licensee and assistant will also review safe sleep regulations and email LPA Chancellor a written acknowledgement of completing and understanding safe sleep regulations.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above where child 1 and 6 were missing records of safe sleep logs. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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LIcensee agrees to complete 15 minute sleep log checks, for all infants under the age of 2. Records need to be updated and available for review during inspection. Licensee will email LPA updated log for this week 5/2-5/5.
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:William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/02/2023 05:36 PM - It Cannot Be Edited


Created By: William M Chancellor Jr. On 05/02/2023 at 04:20 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: 05/02/2023

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
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Based on interview and record review, the licensee did not comply with the section cited above where records were not available for review during inspection for self or assistant. Which poses/posed a potential health, safety or personal rights risk to persons in care. mandatedreporterca.com
POC Due Date: 06/02/2023
Plan of Correction
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LIcensee will email certificates for self and assistant upon completion of mandated reporter training. General and Child care provider trainging needs to be comleted by assistant, licensee only needs to complete childcare provider training.
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
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Based on interview and record review, the licensee did not comply with the section cited above where assistant immunization was missing signature or validated stamp from pharmacy. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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LIcensee will email LPA Chancellor an updated proof of MMR for assistant.
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:William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 05/02/2023 05:36 PM - It Cannot Be Edited


Created By: William M Chancellor Jr. On 05/02/2023 at 04:20 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: 05/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) 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, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Child 2, 5 and 6 are missing prioof of immunizations during inspection. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Licensee agrees to email LPA Chancellor proof of immunizations for child 2, 5 and 6 are missing immunizations.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above where child 6 is missing consent for medical treatment and emergency information cards. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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LIcensee will email LPA Chancellor all licensing forms for child 6. Licensee agrees to not enroll children into daycare until all licensing forms are submitted.
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:William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 05/02/2023 05:36 PM - It Cannot Be Edited


Created By: William M Chancellor Jr. On 05/02/2023 at 04:20 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: 05/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in where current roster was not updated. 10 children were present during inspection and only four were on roster. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Licensee will email LPA Chancellor updated roster will all information for 11 children currently enrolled.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in where child 6 are missing LIC 9227. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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2
3
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LIcensee will email LPA Chancellor updated LIC 9227 for child 6.
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:William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 05/02/2023 05:36 PM - It Cannot Be Edited


Created By: William M Chancellor Jr. On 05/02/2023 at 04:20 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: 05/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above where upon inspection 10 children were present and licensee is only licensed as a small for 8 children max. LIcensee was present with an assistant and both are CPR/First Aid certified. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Licensee will apply for a Large Family Child Care (FCCH) license and follow through with passing fire clearance and necessary clearances to become a Large FCCH. Licensee will update and email LPA Chancellor the progress of applying for grants through RCOE and other available resources to become a Large FCCH. If she does not pass, Licensee agrees to disenroll children and only have a maximum capacity of 8 children at a time.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023


LIC809 (FAS) - (06/04)
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