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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336300485
Report Date: 08/22/2022
Date Signed: 08/22/2022 04:58:37 PM

Document Has Been Signed on 08/22/2022 04:58 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:ROJANO FAMILY CHILD CAREFACILITY NUMBER:
336300485
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 9CENSUS: 6DATE:
08/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Licensee Melissa RojanoTIME COMPLETED:
05:05 PM
NARRATIVE
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On 08/22/2022 LPA Susan Berewer, conducted a case management visit in response to the receipt of an unusual incident report (UIR) from the facility. The Unusual Incident Report, was submitted by Licensee Melissa Rojano, and was received by the licensing agency on 08/18/2022. It indicates that a daycare client reference as Child #8 on the confidential names list, became ill while in attendance at the facility on 08/16/2022, which resulted in the licensee Melissa Rojano calling 911 to request for an ambulance to pick up the child at the facility for treatment at the local hospital.

Facility records were reviewed for Child #8 and the licensee Melissa Rojano, was interviewed regarding the incident. Based on the information gathered by the LPA Susan Brewer, the licensee was not at fault for the incident that took place on 08/16/2022, however the following violation has been identified, where Child #8 was missing the form LIC627 Consent for Medical Treatment, the LIC700 Identification and Emergency Information form and LIC995A Parent's Rights forms were incomplete.

See LIC809D for cited deficiency of the California Code of Regulations, Title 22, Div. 12. 102417(g)(7).

An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to the Licensee Melissa Rojano, on 08/22/2022.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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 2
Document Has Been Signed on 08/22/2022 04:58 PM - It Cannot Be Edited


Created By: Susan Brewer On 08/22/2022 at 04:14 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: ROJANO FAMILY CHILD CARE
FACILITY NUMBER: 336300485

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2022
Section Cited
CCR
102417(g)(7)

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102417(g)(7) An emergency information card shall be maintained for each child and shall include the child's full name... the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement was not met as evidenced by;
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The licensee Melissa Rojano, agrees to obtain the LIC627 Consent for Medical treatment for C8, on or before 08/23/2022 and will ensure that all future children enrolled at the facility prior to attendance at the daycare faciilty will have enrollment forms completed.
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Based on LPA's review of records for Child #8 (C8), the licensee Melissa Rojano, failed to obtain the LIC627 Consent for Medical Care from the parent and a recent incident on 08/16/2022, required medical consent to treat C8, which is an potential risk to the health & safety of children in care.
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.The licensee M. Rojano, agrees to submit proof of the LIC627 form for child #8, on or before 08/24/2022 when the child is expected to return to the facility and submit proof by fax or e-mail to the department along with a statement of understanding the regulation cited.

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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:Pauline Beschorner
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022


LIC809 (FAS) - (06/04)
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