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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844851
Report Date: 06/25/2024
Date Signed: 06/25/2024 09:47:08 AM

Document Has Been Signed on 06/25/2024 09:47 AM - 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:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
334844851
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/25/2024
TYPE OF VISIT:Annual/RandomANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Pristine PerezTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On date and time listed, Licensing Program Analyst (LPA) Sumayya Habeebulla arrived at the facility to conduct an annual inspection as part of a compliance review. Facility was on an inactive status and the annual is being conducted to place the facility on an active status. 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: Sun - Sat, 5 AM to 4 AM

· Off-limit areas include: 2nd floor, Garage, Formal Living Room, Formal Dining Room.

· The facility is licensed to have no more than 8 children as a small FCCH and is operating within the licensed capacity and appropriate ratios.



· There are no children enrolled at this time.

· 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 is functioning and carbon monoxide detector needs to be replaced.

· Fireplace is properly screened to prevent access by children..

· All hazardous items are stored inaccessible to children.

· Toxins are locked.

· Weapons are not present as stated by Licensee. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2024
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 7
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 334844851
VISIT DATE: 06/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
· Stairs are barricaded.

· Clean, safe, and age-appropriate toys

· Roster will be updated after facility enrolls children..

· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are not posted.

· Fire Drill will be conducted once enrollment begins.

· 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 - Licensee will submit Rental Agreement

· No Children enrolled currently.

· No Staff present currently.

· Mandated Reporter Training expired on 06/2024.

· Pediatric CPR and First Aid Card expired on 10/2023.

· Health & Safety Certificate - completed on 11/17/2017


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

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: https://www.ada.gov/resources/child-care-centers/.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 334844851
VISIT DATE: 06/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The Licensee 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-andresources/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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

MyChildCarePlan.org - Licensee [or facility representative] was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 334844851
VISIT DATE: 06/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The 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.



As agreed, upon by the licensee Pristine Perez, the following needs to be corrected/updated immediately -

1. Rental Agreement
2. LIC 9149
3. Picture of the entrance to the formal living room gated
4. Picture of all updated postings
5. Copy of Health & Safety Training
6. Clearance for an adult who may visit facility
7. Mandated Reporter certificate

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov . For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process .

During the exit interview, the LICENSEE Pristine Perez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the licensee Pristine Perez.

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: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/25/2024 09:47 AM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 06/25/2024 at 09:28 AM
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 334844851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in having a functioning carbon monoxide device present at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
1
2
3
4
Licensee agrees to purchase a new device and send a picture of the receipt to the department by teh POC due date.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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 in renewing teh CPR & First AId which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
1
2
3
4
Licensee agrees to renew the CPR & First Aid training by teh POC due date and submit the certificate to the department by the 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:Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7