334846320-12-16-2022-09-CC-KTUR-CM72ZR-20221216165048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334846320
Report Date: 12/16/2022
Date Signed: 12/16/2022 04:51:20 PM

Document Has Been Signed on 12/16/2022 04:51 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:	HERNANDEZ FAMILY CHILD CARE		FACILITY NUMBER:	334846320
ADMINISTRATOR:	HERNANDEZ,JAZMIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(951) 660-5268
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	12/16/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Jazmin Hernandez, Applicant		TIME COMPLETED:	05:00 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) Kay Turner arrived at the facility to conduct a pre-licensing inspection. Present during this inspection were: Jazmin Hernandez, Applicant. LPA toured the facility, inside and out and the following was observed and/or discussed: Normal days and hours of operation are: Monday to Friday 7:00am to 6:00pm OFF-LIMIT AREAS INCLUDE: bedroom #2, bathroom #2 and kitchen. · Appropriate fire extinguisher, smoke detector and carbon monoxide detector are present and were tested by the applicant during this inspection. Fire extinguisher, smoke detector and carbon monoxide detector are in working order. · All hazardous items are inaccessible · Toxins locked · No guns or weapons present as of this date. Applicant understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations. · This is a single-story home · There is no fireplace · Storage of poisons is inaccessible to children and locked · Verification of control of property on file (rental agreement) · Property Owner/Landlord Consent (LIC 9149)/Notification (LIC 9151) on file · Facility Sketch and Emergency Disaster Plan are posted · Mandated Reporter Training expires 11/2023 · Pediatric CPR and First Aid Card - expires 08/2023 · Health & Safety Certificate - completed on 11/28/2022 Fire clearance granted 11/23/2022 · There are no bodies of water as of this date. Applicant understands all bodies of water including ponds, above ground pools and spas, in-ground pools and spas, and some fountains must be properly covered or

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Karrene Turner
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

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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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: HERNANDEZ FAMILY CHILD CARE	FACILITY NUMBER: 334846320
	VISIT DATE: 12/16/2022

NARRATIVE

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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 when not in use.
· Clean, safe and age appropriate toys
· There are no toxic plants observed at this time
· The Applicant 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 12/16/2022 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· The Applicant can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

The following was discussed with the applicant(s):

- Pre-Licensing Visit Packet provided
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months
- Responsibilities of being a mandated reporter
- Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must always be on file with the licensing office
- Baby walkers, baby-bouncer, and walker-jumpers are prohibited (H&S 1500.86(a)(4))

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

LPA discussed the safe sleep regulations with Applicant, Jazmin Hernandez, 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.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Karrene Turner
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

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: HERNANDEZ FAMILY CHILD CARE	FACILITY NUMBER: 334846320
	VISIT DATE: 12/16/2022

NARRATIVE

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LPA also informed Applicant, Jazmin Hernandez, 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 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

Applicant 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

The Applicant, Jazmin Hernandez, 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 applicant, Jazmin Hernandez.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Karrene Turner
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

LIC809 (FAS) - (06/04)

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