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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844818
Report Date: 12/13/2021
Date Signed: 12/13/2021 01:57:56 PM

Document Has Been Signed on 12/13/2021 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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
334844818
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 15CENSUS: 15DATE:
12/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Licensee, Patricia HernandezTIME COMPLETED:
02:15 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Linda Almaraz and Licensing Program Manager (LPM) Carlos Martinez 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 -Friday 5:00AM-6:00PM
· Off-limit areas include: Master bedroom #1, bedroom #2, laundry room and garage.
· The facility is not operating within the licensed capacity- LPA's confirmed a census of 15 children at time of visit.
· Appropriate supervision provided during this inspection.
· A working telephone is present and the current number is on file.
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· Fireplace is barricaded with furniture 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
· Clean, safe and age appropriate toys.
· Roster on file but was not current.
· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted
· Documentation of fire and disaster drills was not on file.
(Continued on an LIC 809C)
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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 10
Document Has Been Signed on 12/13/2021 01:57 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 12/13/2021 at 12:03 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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021

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 observation and record review, the licensee did not comply with the section cited above. LPA's confirmed there was 15 children at one point during the morning at the facility which poses an immediate health, safety risk to children in care.
POC Due Date: 12/14/2021
Plan of Correction
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The licensee agreed to operate within the capacity limitations of the license. Licensee agreed to provide care and supervision to a maximum of 8 children only. A signed written statement will be submitted to CCL by POC due date.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2021 01:57 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 12/13/2021 at 12:03 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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Bedroom #3, which is accessible to children, has several holes on the wall which have not been repaired. Licensee, LPM and LPA confirmed a total of 4 holes on the walls. A light switch in the hall way was broken which poses a potential health, safety risk to children in care.
POC Due Date: 12/20/2021
Plan of Correction
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Licensee will repair all holes in the wall and light switch. Pictures of repairs will be send to CCL by POC due date.
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. The Licensee did not have records of fire and disaster drills conducted which poses a potential health, safety risk to children in care.
POC Due Date: 12/20/2021
Plan of Correction
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Licensee will conducted a fire drill by the end of the week, will document it and send proof to CCL by POC due date. Licensee agrees to complete drills every 6 months.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 12/13/2021 01:57 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 12/13/2021 at 12:03 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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Children #6-15 did not have an LIC 995A on file which poses a potential health, safety risk to children in care.
POC Due Date: 12/17/2021
Plan of Correction
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Licensee agrees to provide an LIC 995A to all parents or authorized representative and obtain a signature and date the bottom portion of the notice form. A copy will be maintain the child's file. Licensee will send a copy to CCL by POC due date.

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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2021 01:57 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 12/13/2021 at 12:03 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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021

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 record review, the licensee did not comply with the section cited above. The Licensee and Staff #2 did not have Mandated Reporter training on file which poses a potential health, safety risk to children in care.
POC Due Date: 01/12/2022
Plan of Correction
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Licensee will ensure Mandated Reported training is completed for herself and Staff #2, and will send proof of completion to CCL by POC due date.
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 on record review, the licensee did not comply with the section cited above. Licensee and Staff #2 did not have immunization records on file which poses a potential health, safety risk to children in care.
POC Due Date: 01/12/2022
Plan of Correction
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Licensee will ensure immunization records are completed and on file for both, herself and Staff #2. A copy of Immunization records will be sent to CCL by POC due date.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 12/13/2021 01:57 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 12/13/2021 at 12:03 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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(d)
Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee and Staff #2 did not have a completed personnel file at the home which poses a potential health, safety risk to children in care.
POC Due Date: 12/27/2021
Plan of Correction
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Licensee will ensure a file for Staff #2 and herself is completed and will send a copy of files to CCL by POC due date.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Staff #2 was hired on 12/2020 and did not have proof of vaccination of file which poses a potential health, safety risk to children in care.
POC Due Date: 12/14/2021
Plan of Correction
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Licensee agrees to ensure all employees and volunteers obtain immunization records prior to commencement of employment.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021


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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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844818
VISIT DATE: 12/13/2021
NARRATIVE
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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 Patricia Hernandez. 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: Carlos Martinez
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 12/13/2021 01:57 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 12/13/2021 at 12:03 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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above. The licensee did not have on file an LIC 627 for Children #8-15 which poses a potential health, safety risk to children in care.
POC Due Date: 12/17/2021
Plan of Correction
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Licensee agreed to provide a copy of LIC627 to parents, and once completed to maintain a copy on each childs file by POC due date. A copy of each form will be sent to CCL by POC due date.
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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2
3
4
Based on record review, the licensee did not comply with the section cited above. Children #1-5 and #8-15 did not have immunization records on file which poses a potential health, safety risk to children in care.
POC Due Date: 12/17/2021
Plan of Correction
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Licensee agreed to obtain a copy of immunization from parents and maintain in the child's file. A copy of each record will be sent to CCL by POC due date.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021


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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844818
VISIT DATE: 12/13/2021
NARRATIVE
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· 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.
· Verification of control of property on file
· Children’s records are incomplete
· Employee’s records are incomplete
· Mandated Reporter Training was not on file for Licensee and Staff #1.
· Pediatric CPR and First Aid Card expires on 3/2022.
· Health & Safety Certificate - completed on 11/17/18
· 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

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

(Continued on an LIC 809C)
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 12/13/2021 01:57 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 12/13/2021 at 12:03 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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Children #8-15 did not have an emergency information card on file which poses a potential health, safety risk to children in care.
POC Due Date: 12/17/2021
Plan of Correction
1
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3
4
Licensee agrees to obtain an LIC 700 Identification and Emergency Information form for each child and maintain it on file. A copy will be sent to CCL by POC due date.
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Licensee did not have a current updated child roster with all children attending which poses a potential health, safety risk to children in care.
POC Due Date: 12/14/2021
Plan of Correction
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Licensee will update Child roster and send a copy to CCL by POC due date.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021


LIC809 (FAS) - (06/04)
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