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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846142
Report Date: 11/16/2022
Date Signed: 11/16/2022 01:00:35 PM

Document Has Been Signed on 11/16/2022 01:00 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:PACHECO-ESTRADA FAMILY CHILD CAREFACILITY NUMBER:
334846142
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Brandy Pacheo-Estrada, LicenseeTIME COMPLETED:
01:25 PM
NARRATIVE
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On date and time listed, Licensing Program Analysts (LPA) Elyse Jones and Blanca Silva 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 6:00AM-11:00PM

OFF-LIMIT AREAS INCLUDE: Front closet, Bedroom #1, Bedroom #2, Bedroom #3, hallway shelves, hallway closet, and Garage

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
· One story home
· Verification of control of property on file (Lease Agreement)
· Property Owner/Landlord Consent (LIC 9149)/Notification (LIC 9151) on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training expires on 8-4-23
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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Document Has Been Signed on 11/16/2022 01:00 PM - It Cannot Be Edited


Created By: Elyse Jones On 11/16/2022 at 10:59 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PACHECO-ESTRADA FAMILY CHILD CARE
FACILITY NUMBER: 334846142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

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 an immediate Health, Safety & Personal Rights risk to the children in care. Upon arrival LPAs observed S1 providing supervision & care along side the Licensee. However, S1 does not have a clearance and is not associated to the facility and has been working for two weeks.
POC Due Date: 11/17/2022
Plan of Correction
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Licensee agrees to submit required documentation for clearance and association to the department by close of business on 11-17-22. Licensee understands S1 cannot return to the facility to work, reside or volunteer until a clearance is obtained.

$500 Civil Penalty assessed. $100/per day x 5 days.
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: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/16/2022 01:00 PM - It Cannot Be Edited


Created By: Elyse Jones On 11/16/2022 at 10:59 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PACHECO-ESTRADA FAMILY CHILD CARE
FACILITY NUMBER: 334846142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(f)
Operation of A Family Child Care Home
(f) If food is brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated.

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. Upon arrival LPAs observed approximately four unlabeled bottles.
POC Due Date: 11/30/2022
Plan of Correction
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Licensee agrees to read the regulation and submit a statement stating she understands to the regulation. The statement is due on or by the POC due date.
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 and interview the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. Upon arrival the Licensee stated she did not have a file available for review for S1.
POC Due Date: 11/30/2022
Plan of Correction
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Licensee agrees to have S1 complete required documents and submit to her prior to returning to work. Licensee agrees to create a file for S1 and understands that all staff require a file to be avilable for review.
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: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/16/2022 01:00 PM - It Cannot Be Edited


Created By: Elyse Jones On 11/16/2022 at 10:59 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PACHECO-ESTRADA FAMILY CHILD CARE
FACILITY NUMBER: 334846142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022

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
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Based on the record review and interview the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. Upon arrival the Licensee stated she did not have a file available for review for C1.
POC Due Date: 11/30/2022
Plan of Correction
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Licensee agrees to have the Authorized Representatives for C1 submit all required documents for enrollment. Licensee understands all children must have a file with all required documents available for review during inspection.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review and interview the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. LPAs were unable to review current sleeping log for C2 and C3.
POC Due Date: 11/30/2022
Plan of Correction
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Licensee agrees to complete sleep logs for C2 and C3 from today's inspection and forward. Licensee understands all children up to the age of 24 months must have a sleep log on file.
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: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/16/2022 01:00 PM - It Cannot Be Edited


Created By: Elyse Jones On 11/16/2022 at 11:28 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PACHECO-ESTRADA FAMILY CHILD CARE
FACILITY NUMBER: 334846142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
(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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Based on the observation the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. During the facility tour LPA observed C3 sleeping in a crib with a bottle, folded blanket and Boppy pillow.
POC Due Date: 11/30/2022
Plan of Correction
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Licensee agrees to read the Safe Sleep regulations and write a statement stating she understands the regulations in its entirety. State will be submitted to the Department on or by POC due date.
Type B
Section Cited
HSC
1597.54(d)
(d) Evidence of ac urrent tuberculosis clearance, as defined in regulations that the department shall adopt, for any adult in the home during the time that chidlren are under care. This requirement may be satisfied by a current certificate, as defined in subdivision (f) of Section 121525, that indicates freedom from infectious tuberculosis as set forth in Section 121525.

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. Medical documentation provided for the Licensee’s Assistant (Staff #2) during the inspection was unclear regarding current TB clearance status. Follow up information has been requested to comply with the above regulation.
POC Due Date: 11/30/2022
Plan of Correction
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Licensee agrees to submit proof of TB clearance for S2 to the department on or 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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


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: PACHECO-ESTRADA FAMILY CHILD CARE
FACILITY NUMBER: 334846142
VISIT DATE: 11/16/2022
NARRATIVE
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· Pediatric CPR and First Aid Card expires on 8-2023
· Health & Safety Certificate - completed on 8-29-21
· 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 10-12-22
· 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 11-16-22 indicate that all adults who require caregiver background checks have NOT 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 Licensee Brandy Pacheco-Estrada 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 Brandy Pacheco-Estrada 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: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
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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: PACHECO-ESTRADA FAMILY CHILD CARE
FACILITY NUMBER: 334846142
VISIT DATE: 11/16/2022
NARRATIVE
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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

- Licensee Brandy Pacheco-Estrada 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

Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

See LIC809-D for cited deficiencies.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
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: PACHECO-ESTRADA FAMILY CHILD CARE
FACILITY NUMBER: 334846142
VISIT DATE: 11/16/2022
NARRATIVE
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The Licensee Brandy Pacheco-Estrada confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

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 Licensee Brandy Pacheco-Estrada.

A notice of site visit was given and must remain posted for 30 days.

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

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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