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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623039
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:32:19 PM

Document Has Been Signed on 07/20/2023 01:32 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PERALES, ERESVEYFACILITY NUMBER:
343623039
ADMINISTRATOR:ERESVEY PERALESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 674-6988
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 15DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Eresvey PeralesTIME COMPLETED:
02:00 PM
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On 07/20/2023, Licensing Program Analyst Katy Maestas (LPA) conducted a field visit to the Family Childcare Home (FCCH) for the purpose of an unannounced annual inspection. LPA arrived at the FCCH and was met by Licensee Eresvey Perales (L1). LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. LPA observed 9 school aged children, 4 preschool aged children and 2 infants being supervised by L1 and 1 Aide. Also present in the FCCH was L1’s adult and minor child. LPA accessed Guardian to determine that all required adults were background cleared and associated with the license. L1 stated there are no new residents in the home since licensure. LPA toured the areas of the FCCH that are accessible to children in care. L1 accompanied LPA for the entirety of the tour. The OFF-limits areas of the FCCH include the entire upstairs, laundry room and garage. L1 acknowledged that children may never enter these OFF-limits areas. L1 reports her hours of operation to be Monday through Friday from 7:00 am until 6:00 pm. L1 stated that she does not provide overnight or weekend care.

LPA conducted a file review before arrival at the FCCH. LPA provided the Entrance Checklist to L1. LPA discussed the required postings in a FCCH with L1 and ensured that postings are current. LPA reviewed the children’s files for those who were in attendance. LPA reviewed the adult’s files and immunizations. LPA reviewed the Facility’s Roster and observed the Fire Drill log to ensure that drills are conducted at least once every 6 months. A functioning dual smoke and carbon monoxide detector was observed in the dining room and tested. L1 stated that cleaners and detergents are stored in the OFF-Limits laundry room. LPA observed medications stored in kitchen cabinets that are high up and out of reach to children in care. LPA observed knives stored in kitchen cabinets that are high up and out of reach to children in care. LPA observed a baby-gate barricading the stairway to make the stairs inaccessible to children. LPA observed a 2A10BC fire extinguisher in the kitchen that appeared to be in the green zone. Toys appeared to be safe and in good supply. LPA did not observe any pool, spa nor any water feature.

Continued on 809-C

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PERALES, ERESVEY
FACILITY NUMBER: 343623039
VISIT DATE: 07/20/2023
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LPA walked the perimeter of the backyard and ensured the stability of the surrounding fence. L1 stated there are no firearms in the home. L1 stated that she owns 2 dogs.

LPA discussed Mandated Reporter Training with the L1. Health and Safety Code 1596.8662 requires that all licensed providers, applicants, directors, and employees complete training as specified on their mandated reporter duties and renew their training every 2 years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at http://www.mandatedreporterca.com/. The training is currently provided in English and Spanish. L1 has a current Mandated Reporter Training Certificate which will expire on 04/26/2024. Current Pediatric CPR and First Aid training was also verified by LPA and expires on 01/09/2024.

LPA discussed the Safe Sleep Regulations with L1 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 L1 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 that s/he register all infant devices with the CPSC to be notified of any recalls on 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: https://www.ada.gov/resources/child-care-centers/.

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 through this communication platform. To receive important licensed related information, 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.

Continued on LIC 809-C

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
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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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PERALES, ERESVEY
FACILITY NUMBER: 343623039
VISIT DATE: 07/20/2023
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L1 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.

L1 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.

L1 understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. L1 understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report/LIC 624 shall be submitted within 7 days to remain in compliance. L1 understands that if any structural changes are made to the home; licensing must be notified PRIOR to construction. L1 understands that if she wants to make any OFF-limits area an ON-limits area, she must notify licensing and LPA must do an inspection BEFORE children are allowed in said area. L1 understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to 3 years.



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.

As a result of caring for more children than the maximum capacity allows, a deficiency was cited on subsequent 809-D page. L1 understands that all parents or authorized representatives of currently enrolled children, and also parents or authorized representatives of newly enrolled children for up to 1 year, must sign the LIC 9224 form be available to the Department for review. An exit interview was conducted, and the report was reviewed with L1. LPA provided Licensee Appeal Rights to L1. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
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Document Has Been Signed on 07/20/2023 01:32 PM - It Cannot Be Edited


Created By: Nola Maestas On 07/20/2023 at 01:09 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PERALES, ERESVEY
FACILITY NUMBER: 343623039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation of 15 children in care with, 2 adults the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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L1 and both Aides will watch 2 videos on the CDSS website titled "How Many Children Can Attend a FCCH" and "Supervising Children in FCCH." All 3 individuals will sign a statement aknowledging that they watched the videos and will abide by ratio regulations. The statement will be emailed to LPA by closing on 07/21/2023.
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:Jeanne Smith
LICENSING EVALUATOR NAME:Nola Maestas
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


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