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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844715
Report Date: 06/29/2023
Date Signed: 06/29/2023 02:21:54 PM

Document Has Been Signed on 06/29/2023 02:21 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:CORDOVA FAMILY CHILD CAREFACILITY NUMBER:
334844715
ADMINISTRATOR:CORDOVA,GABRIELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 396-0973
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Gabriela Cordova, LicenseeTIME COMPLETED:
02:30 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Elyse Jones and Blanca Ruiz arrived at the facility to conduct annual inspection. 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-Friday 6:00AM-6:00PM

OFF-LIMIT AREAS INCLUDE: Backyard, Garage, Room 1, Room 2, Room 3 and Master Bedroom

The facility is operating within the licensed capacity and appropriate ratios


· Appropriate supervision provided during this inspection
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were 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
· Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Single story
· Verification of control of property on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training completed 10-7-2022
· Pediatric CPR and First Aid Card expires on 6/2023
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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 9
Document Has Been Signed on 06/29/2023 02:21 PM - It Cannot Be Edited


Created By: Elyse Jones On 06/29/2023 at 12:44 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: CORDOVA FAMILY CHILD CARE
FACILITY NUMBER: 334844715

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(h)
Infant Safe Sleep
Car seats shall only be used for transportation purposes and shall not be used for sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation, the Licensee did not meet the above regulation which poses an immediate Health, Safety & Personal Rights risk to the children in care. During the facility tour LPAs observed C2 sleeping in a car seat.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee agrees to submit a written statement of understanding of the regulation.
Type A
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation, the Licensee did not meet the above regulation which poses an immediate Health, Safety & Personal Rights risk to the children in care. Upon arrival LPAs observed S2 and S4 in the outside play area with a group of children. During the facility tour S2 disclosed there was a sleeping baby in the garage. LPA observed C2 behind a closed door in an off limits garage.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee agrees to submit a written statement of understanding of the regulation.
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:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2023 02:21 PM - It Cannot Be Edited


Created By: Elyse Jones On 06/29/2023 at 12:44 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: CORDOVA FAMILY CHILD CARE
FACILITY NUMBER: 334844715

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 the record review, the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. LPA was unable to review a sleep log for C2.
POC Due Date: 07/06/2023
Plan of Correction
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Licensee agrees to submit a written statement of understanding of the regulation. Licensee also agrees to create a sleep log, document C2 until 7/6/2023 and submit to the Department on 7/6/2023.
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 the record review, the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. LPA was unable to review a Mandated Reporter for S3 and S4.
POC Due Date: 07/06/2023
Plan of Correction
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Licensee also agrees to have S3 and S4 complete the Mandated Reporter training and submit a certificate of completion to the Departmetn.
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:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 06/29/2023 02:21 PM - It Cannot Be Edited


Created By: Elyse Jones On 06/29/2023 at 12:44 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: CORDOVA FAMILY CHILD CARE
FACILITY NUMBER: 334844715

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. LPA was unable to review a file for S3 and S4. Licensee stated there isn’t a file available for S3 and S4.
POC Due Date: 07/06/2023
Plan of Correction
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Licensee agrees to obtain required documents for the S3 and S4. Licensee understands all employees shall have a file available for review with all required documents.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. LPA was unable to review a file for C1 and C2. Licensee stated there isn’t a file available for C1 and C2.
POC Due Date: 07/06/2023
Plan of Correction
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Licensee agrees to obtain required documents for the C1 and C2. Licensee understands all children shall have a file available for review with all required documents.
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:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 06/29/2023 02:21 PM - It Cannot Be Edited


Created By: Elyse Jones On 06/29/2023 at 12:44 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: CORDOVA FAMILY CHILD CARE
FACILITY NUMBER: 334844715

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on the record review, the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. LPA was unable to review a LIC 9227 for C2. Licensee stated C2 does not have a LIC 9227 for C2.
POC Due Date: 07/06/2023
Plan of Correction
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Licensee agrees to obtain an LIC 9227 for C2 and submit to the Department.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2023 02:21 PM - It Cannot Be Edited


Created By: Elyse Jones On 06/29/2023 at 12:52 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: CORDOVA FAMILY CHILD CARE
FACILITY NUMBER: 334844715

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102371(a)
(a) A fire safety clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal shall be required for a large family child care home.

This regulation was not met as evidenced by:
Deficient Practice Statement
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Based on the observation and record review, the Licensee did not meet the above regulation which poses an immediate Health, Safety & Personal Rights risk to the children in care. During the facility tour LPAs observed a child sleeping in the garage which is an off limits area. During the file review the fire clearance was reviewed and states, “… was advised the occupancy of a garage does not permit living and/or child care activities."
POC Due Date: 06/30/2023
Plan of Correction
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Licensee agrees to submit a written statement of understanding of the Fire Clearance.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


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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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CORDOVA FAMILY CHILD CARE
FACILITY NUMBER: 334844715
VISIT DATE: 06/29/2023
NARRATIVE
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·Health & Safety Certificate - completed on 10/15/2017
· No bodies of water at this time. 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.
· Clean, safe and age appropriate toys
· Current roster on file
· Documentation of fire and disaster drills on file – Last drill conducted on 1/5/2023
· Children’s records are NOT complete
· Employee’s records are NOT complete
· 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

· Resident and/or staff records reviewed on 6/29/2023 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

- LPA discussed the safe sleep regulations with Gabriela Cordova, Licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Gabriela Cordova, 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: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CORDOVA FAMILY CHILD CARE
FACILITY NUMBER: 334844715
VISIT DATE: 06/29/2023
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

- Gabriela Cordova, Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

- Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. 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.


- 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.

The Gabriela Cordova, Licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CORDOVA FAMILY CHILD CARE
FACILITY NUMBER: 334844715
VISIT DATE: 06/29/2023
NARRATIVE
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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.

Exit interview conducted and report was reviewed with the Gabriela Cordova, Licensee.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
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