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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623145
Report Date: 11/19/2021
Date Signed: 11/19/2021 11:18:02 AM

Document Has Been Signed on 11/19/2021 11:18 AM - 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:CRUZ, GRISELDAFACILITY NUMBER:
343623145
ADMINISTRATOR:CRUZ, GRISELDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 997-3283
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY: 14TOTAL ENROLLED CHILDREN: 2CENSUS: 2DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Griselda CruzTIME COMPLETED:
11:30 AM
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On 11/19/21 Licensing Program Analyst (LPA) Fabiola Diaz met with licensee Griselda Cruz unannounced annual inspection/1 year inspection. Present in the facility were 2 children. Licensee's parents in-law were visiting.

The one story home has a unfenced front yard, 3 bedrooms, 1 bathroom, garage, kitchen, living room, dining room, laundry room, and fenced backyard. On today's date licensee updated the off-limits areas in the home to be: Bedroom #2 and #3, garage, and laundry room. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. Licensee acknowledges that children may never enter these off-limit areas. Licensee was notified that prior to use of any off limits area, the department must be notified.

A health and safety inspection was conducted in the areas accessible to children. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. Licensee stated there are no weapons in the home. Cleaning compounds and hazardous items were inaccessible to children. Safe toys and play equipment were observed. LPA discussed and observed all the required postings. LPA advised the licensee that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock.

LPA observed licensee's immunization record in the facility file. Children's roster was observed. A fire drill log was not observed, but licensee stated she did a fire drill with the day care children about 4 weeks ago. Licensee's CPR/First aid card was expired with an expiration date of 3/16/21, and licensee has enrolled for a course for December 9, 2021. Mandated Reporter Training for licensee expired on 4/4/21. Licensee understands training must be complete every two years. LPA observed children's files and the files contained the LIC Emergency forms.
Report continues on 809C.....
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Fabiola Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: CRUZ, GRISELDA
FACILITY NUMBER: 343623145
VISIT DATE: 11/19/2021
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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

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee 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.

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.

Licensee was reminded that all adults 18 and over, 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.

A Title 22 Deficiency is being cited on today's date on LIC809 D. Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days. Exit interview was conducted and report was reviewed with the licensee Griselda Cruz.

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Fabiola Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2021 11:18 AM - It Cannot Be Edited


Created By: Fabiola Diaz On 11/19/2021 at 10:45 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: CRUZ, GRISELDA
FACILITY NUMBER: 343623145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2021
Plan of Correction
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Licensee will provide with a current EMSA approved pediatric CPR/First Aid by POC due date. Licensee explained she is signed up to take the course on 12/09/21.
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:Roxana Saravia
LICENSING EVALUATOR NAME:Fabiola Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


LIC809 (FAS) - (06/04)
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