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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623966
Report Date: 10/14/2021
Date Signed: 10/14/2021 10:52:42 AM

Document Has Been Signed on 10/14/2021 10:52 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:QUERO-FLORES, MARTHAFACILITY NUMBER:
343623966
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
10/14/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Martha Quero-FloresTIME COMPLETED:
11:00 AM
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On Thursday, October 14, 2021 at 9:00 AM, Licensing Program Analyst (LPA) Tanya Washington met with Applicant, Martha Quero- Flores for an announced Pre-Licensing inspection. Applicant plans to operate seven days a week, 24 hours a day. Applicant understands that she may not provide care to the same family for more than 24 hours a day. Applicant and all adults residing in the home have received a criminal background clearance and are all associated to the facility.

LPA and Applicant toured the single story home which has five bedrooms, three bathrooms, front room "classroom", living room, dining room, kitchen, laundry room and a fenced backyard. Applicant owns the home and a copy of the mortgage statement was provided as proof of control of property. Applicant does not have liability insurance and will have parents fill out an affidavit.

Off-limit areas will consist of all five bedrooms, laundry room, shed in the backyard and the portion of the backyard behind the shed which is fenced off. Applicant stated that in the future, she plans to utilize the bedroom and bathroom for daycare children which is located near the living room. Applicant was advised to contact Licensing Office prior to opening up the room for children so it can be inspected. Applicant understands that children may never enter the off-limits areas of the home and the doors to the off limits rooms must be closed when day-care children are present. Applicant acknowledges she is required to notify licensing prior to making changes to off-limit areas so that they may be inspected for safety.

Continued on LIC809C
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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 4
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: QUERO-FLORES, MARTHA
FACILITY NUMBER: 343623966
VISIT DATE: 10/14/2021
NARRATIVE
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LPA observed a carbon monoxide detector, a functional smoke detector and a 2A10BC fire extinguisher. Applicant had accessible cleaning supplies and some poison accessible in the laundry room. Applicant does not have a door on her laundry room and will relocate items out of reach and install a safety gate. Applicant understands that poisons must be locked.
Applicant plans to utilize her backyard for outdoor play. She is aware that 100% supervision must be maintained at all times when children are around bodies of water or in unfenced areas. Applicant stated there are no firearms in the home. There are no bodies of water on the premises.

Applicant has completed the required EMSA certified CPR and First Aid class which is valid until 03/03/2023. Applicant has completed the required Preventative Health and Safety training and the required Lead Testing course. Applicant provided proof of her immunizations for her self. Applicant has also completed Mandated Reporter Training certification which is valid until 08/12/2022.

LPA discussed current COVID-19 guidelines, postings, and protocols. LPA discussed Type A and Type B citations, Zero Tolerance, and Civil Penalties. LPA discussed open door policy, supervision, fire drills, children’s personal rights, reporting requirements, and the smoking prohibition with the applicant. A current roster of children enrolled must be available and maintained for a period of three years, even after children are no longer in care.

Annual fees must be paid promptly and by the due date or late fees will be assessed. Applicant understands that the license is non-transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if she relocates and wants to continue to provide care, she must submit a change of location application and have the new home inspected.


Continued on LIC809C
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: QUERO-FLORES, MARTHA
FACILITY NUMBER: 343623966
VISIT DATE: 10/14/2021
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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 provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the applicant can request to be added to the distribution list to receive Quarterly Updates. LPA provided form LIC311D and discussed the required forms for children's records, employee records, and forms required to be kept on file at the facility. LPA provided the Licensing Agency website (WWW.CCLD.CA.GOV), so that the applicant may obtain updated licensing information, regulations, PINs, and forms.




Prior to licensure the following items must be corrected:
- LPA must inspect the shed area which was locked during the inspection and Applicant was unable to open it.
- Lock all poisons and gardening tools
- Relocate items that may fall off the shelf in the backyard area
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SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: QUERO-FLORES, MARTHA
FACILITY NUMBER: 343623966
VISIT DATE: 10/14/2021
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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 provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the applicant can request to be added to the distribution list to receive Quarterly Updates. LPA provided form LIC311D and discussed the required forms for children's records, employee records, and forms required to be kept on file at the facility. LPA provided the Licensing Agency website (WWW.CCLD.CA.GOV), so that the applicant may obtain updated licensing information, regulations, PINs, and forms.

Prior to licensure the following items must be corrected:
- Post required licensing forms
- Gain access to the shed located in the back yard
- Make all gardening tools in the front and back yard inaccessible to children (including tall ladder)
- Lock all poisons
- Make laundry room cleaning supplies inaccessible
- Relocate items on the shelf located in the backyard to prevent from falling


LPA will return for a follow up visit on 10/26/2021.


SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
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