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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845880
Report Date: 10/14/2021
Date Signed: 10/14/2021 04:07:55 PM

Document Has Been Signed on 10/14/2021 04:07 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:VARGAS FAMILY CHILD CAREFACILITY NUMBER:
334845880
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Adelina VargasTIME COMPLETED:
04:20 PM
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) Samuel Lopez arrived at the facility to conduct a Required/1 Year 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 through Friday, 5:00am to 6:00pm

OFF-LIMIT AREAS INCLUDE: Second floor, garage, and side yards

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 NOT stored inaccessible to children
· Toxins are locked
· Weapons are not present according to the Licensee. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Stairs are barricaded
· Verification of control of property on file (Mortgage Statement)
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training Certificate not available for review
· Pediatric CPR and First Aid Card expire on 4/2022
· Health & Safety Certificate - completed on 8/2020
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Samuel Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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 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: VARGAS FAMILY CHILD CARE
FACILITY NUMBER: 334845880
VISIT DATE: 10/14/2021
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
· 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 was not available for review
· 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: UnusualIncidentReportsDO10@dss.ca.gov
· Resident and/or staff records reviewed on 10/14/2021 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_Disassociations858@dss.ca.gov

- LPA discussed the safe sleep regulations with licensee Adelina Vargas 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 Adelina Vargas 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.

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: Aaron Ross
LICENSING EVALUATOR NAME: Samuel Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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: VARGAS FAMILY CHILD CARE
FACILITY NUMBER: 334845880
VISIT DATE: 10/14/2021
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
- 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.



See LIC 809-D for deficiencies

- 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

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

Exit interview conducted and report was reviewed with the Licensee Adelina Vargas.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Samuel Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/14/2021 04:07 PM - It Cannot Be Edited


Created By: Samuel Lopez On 10/14/2021 at 01:42 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: VARGAS FAMILY CHILD CARE
FACILITY NUMBER: 334845880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(i)
Infant Safe Sleep
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation of an infant sleeping (Child #1) in a Fisher Price baby rocker/sleeper, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2021
Plan of Correction
1
2
3
4
The licensee removed the child from the sleeper during the inspection. The licensee agrees to submit a written statement detailing that she reviewed and understood the regulations regarding Infant Safe Sleep (102425). Statement to be submitted to the Riverside Child Care Regional Office by 10/15/2021.
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:Aaron Ross
LICENSING EVALUATOR NAME:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/14/2021 04:07 PM - It Cannot Be Edited


Created By: Samuel Lopez On 10/14/2021 at 01:42 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: VARGAS FAMILY CHILD CARE
FACILITY NUMBER: 334845880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations made while touring the backyard. The play structure/swing set was not anchored, heavy pieces of floor tile in an upright position, which have the potential to fall on children were also observed. The licensee did not comply with the section cited above. However, the children are not currently utilizing the backyard for play due to weather conditions and improvements being made. This still poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2021
Plan of Correction
1
2
3
4
Licensee agrees to anchor the play structure prior to allowing children to play in the backyard. Licensee also agrees to remove or make all other items inaccessible to the children in care. Licensee agrees to submit proof of all corrections to the Riverside Child Care Regional Office by 10/21/2021.
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:Aaron Ross
LICENSING EVALUATOR NAME:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 10/14/2021 04:07 PM - It Cannot Be Edited


Created By: Samuel Lopez On 10/14/2021 at 01:42 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: VARGAS FAMILY CHILD CARE
FACILITY NUMBER: 334845880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

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. The licensee stated that she conducted drills however, did not document/log them, and did not provide documentation for review. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2021
Plan of Correction
1
2
3
4
Licensee agrees to conduct a fire/disaster drill, log it, and submit a copy of the log to the Riverside Child Care Regional Office by 10/21/2021.

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:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 10/14/2021 04:07 PM - It Cannot Be Edited


Created By: Samuel Lopez On 10/14/2021 at 01:42 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: VARGAS FAMILY CHILD CARE
FACILITY NUMBER: 334845880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021

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
1
2
3
4
Based on record review, the licensee and her staff did not have proof of completion, of the Mandated Reporter Training required. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2021
Plan of Correction
1
2
3
4
Licensee agrees to complete the required training and have her staff do the same. The licensee agrees to submit copies of the certificates to the Riverside Child Care Regional Office by 10/28/2021.
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. In reviewing children records (Child #1-#3), the required forms were not signed by the parent/guardian, as required. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2021
Plan of Correction
1
2
3
4
Licensee agrees to submit copies of the forms, competed/signed, to the Riverside Child Care Regional Office by 10/21/2021.
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:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


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