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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623193
Report Date: 09/13/2021
Date Signed: 09/13/2021 01:18:59 PM

Document Has Been Signed on 09/13/2021 01:18 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:MEDEIROS, MARIAFACILITY NUMBER:
343623193
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Maria MedeirosTIME COMPLETED:
01:30 PM
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On Monday, 09/13/21, at 11:45am, Licensing Program Analyst (LPA) Jan Hoshida conducted an unannounced random annual inspection and met with Licensee Maria Medeiros. Upon arrival, LPA observed there were no day care children present in the facility during this inspection. The off-limit areas the entire upstairs, office, backyard, and garage. Licensee acknowledged that children may never enter these off-limit areas. Licensee stated there are no new residents in the home since licensure. All adult residents have criminal record clearances. The hours of operation are Monday through Friday from 7:00am to 6:00pm and additional hours upon request. Also present during the inspection was Licensee’s Assistant.

LPA observed current CPR/First Aid certificate for Licensee and Assistant which expire on 05/2023. LPA reviewed some children’s files. LPA observed fire drills were conducted at least once every six months and documented. LPA observed that there were no hazardous items accessible to children. LPA observed fireplace which was screened. LPA observed that cleaning materials were inaccessible. Fire extinguisher, smoke detector, and carbon monoxide detector meet regulation. Toys appear to be safe. The backyard is fenced and gated. Licensee stated that she does not have any weapons in the home. LPA discussed current COVID guidelines with Licensee. LPA checked facilities fees and confirmed that it is up to date.

LPA did not observe current Mandated Reporter training for herself and Assistant. LPA did not observe proof of immunizations for MMR and Tdap for Licensee.

LPA observed that the off-limits office is a room without a door that opens into the kitchen area. Licensee stated that she maintains 100% supervision at all times to ensure that the children do not enter into the office area. LPA stated that if 100% supervision is not maintained, Licensee should install a gate between the office and kitchen areas.

REPORT CONTINUED ON NEXT PAGE

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Jan Hoshida
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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: MEDEIROS, MARIA
FACILITY NUMBER: 343623193
VISIT DATE: 09/13/2021
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Licensee 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.

This facility does not currently provide Incidental Medical Services- IMS. 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 provided Licensee the Safe Sleep PIN 20-24 CCP and Infant Individual Sleeping Plan (LIC 9227). Licensee stated that she does not currently have any children under that age of two years. LPA discussed the safe sleep regulations with licensee 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 licensee [facility representative] 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.

In the areas that were evaluated, deficiencies were observed at the time of the visit and cited on LIC 809-D. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Maria Medeiros.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Jan Hoshida
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2021 01:18 PM - It Cannot Be Edited


Created By: Jan Hoshida On 09/13/2021 at 01:04 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: MEDEIROS, MARIA
FACILITY NUMBER: 343623193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. This requirement was not met by: LPA observed that Licensee and Licensee's assistant did not have current Mandated Reporter training certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2021
Plan of Correction
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Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. This requirement was not met by: LPA observed that Licensee did not have proof of immunizations for MMR and Tdap which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2021
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:Seychelle De Luca
LICENSING EVALUATOR NAME:Jan Hoshida
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2021


LIC809 (FAS) - (06/04)
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