364816367-6-27-2024-09-CC-TBEN-D6MR3X-20240627124039

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364816367
Report Date: 06/27/2024
Date Signed: 06/27/2024 12:41:02 PM

Document Has Been Signed on 06/27/2024 12:41 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	CRISTOBAL FAMILY CHILD CARE		FACILITY NUMBER:	364816367
ADMINISTRATOR/ DIRECTOR:	CRISTOBAL, AGNES		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 475-2061
CITY:	FONTANA	STATE: CA	ZIP CODE:	92336
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 9	CENSUS: 6	DATE:	06/27/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:05 AM
MET WITH:	Agnes Cristobal, Licensee		TIME VISIT/ INSPECTION COMPLETED:	12:50 PM

NARRATIVE

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On date and time listed, Licensing Program Analysts (LPAs) Taityana Benson and Elyse Jones arrived at the facility to conduct a required/annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:
Normal days and hours of operation are: Monday – Friday, 6:00 a.m. – 6:00 p.m.

OFF-LIMIT AREAS INCLUDE: Entire 2^nd Floor, Back Yard-Right Side Yard (when facing the house) , and Garage

The facility is operating within the licensed capacity and appropriate ratios

· Appropriate supervision provided during this inspection
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· All hazardous items are stored inaccessible to children
· Toxins are locked
· Weapons are not present according to Licensee, Agnes Cristobal. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Stairs are barricaded
· Verification of control of property on file (Mortgage Statement)
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training expires on 08/18/2024
· Pediatric CPR and First Aid Card expired on 03/06/2023

Report Continued On LIC809-C

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

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 9

Document Has Been Signed on 06/27/2024 12:41 PM - It Cannot Be Edited

Created By: Taityana Benson On 06/27/2024 at 11:57 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CRISTOBAL FAMILY CHILD CARE	FACILITY NUMBER: 364816367
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102416.3(a)

Alterations to Existing Building or Grounds

(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review and facility tour, the Licensee did not meet the above regulation which poses an immediate Health and Safety risk to the children in care. During the facility tour the LPAs observed a child in an area that the Licensee designated as “off limits” after the last annual and did not notify the department. LPAs observed medication, biohazard items, oxygen machines and other hazardous items that should be made inaccessible to the children in care.
	POC Due Date: 07/15/2024
	Plan of Correction
1 2 3 4	Licensee understands change in “off limit” areas must be reported to the Department. Licensee agrees “off limit” areas must be made inaccessible to children in care. Licensee agrees to send pictures of the room being made inaccessible and a written statement on how she plans to remain in compliance. Both are due to the Department on or by POC due date of 6/28/2024 via email to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Aaron Ross

LICENSING EVALUATOR NAME:

Taityana Benson

LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC809 (FAS) - (06/04)

Page: 2 of 9

Document Has Been Signed on 06/27/2024 12:41 PM - It Cannot Be Edited

Created By: Taityana Benson On 06/27/2024 at 11:57 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CRISTOBAL FAMILY CHILD CARE	FACILITY NUMBER: 364816367
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the facility tour the Licensee did not meet the above regulation which poses a potential Health to the children in care. During the facility tour the LPA observed dog feces in the children’s outdoor play area. The Licensee stated the children have not played in the back yard today. However, the LPA observed an excessive amount that was and was not fresh.
	POC Due Date: 07/15/2024
	Plan of Correction
1 2 3 4	Licensee understands the children’s outdoor play area must be free of dog feces prior to children playing in the backyard. Licensee agrees to submit pictures of the area cleaned up on or by POC due date of 7/15/2024.

Type B

Section Cited

CCR

102417(g)(9)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, the Licensee did not meet the above regulation which poses a potential safety risk to the children in care. During the file review the LPA was unable to verify if the last fire drill was conducted in the 2023 or 2024.
	POC Due Date: 07/15/2024
	Plan of Correction
1 2 3 4	Licensee understands that fire drills must be completed once every six months per regulation. Licensee agrees to conduct a fire drill with the children in care and submit documentation to the Department on or by 7-15-2024. Licensee was advised to document the month/date/year.

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:

Aaron Ross

LICENSING EVALUATOR NAME:

Taityana Benson

LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC809 (FAS) - (06/04)

Page: 3 of 9

Document Has Been Signed on 06/27/2024 12:41 PM - It Cannot Be Edited

Created By: Taityana Benson On 06/27/2024 at 11:57 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CRISTOBAL FAMILY CHILD CARE	FACILITY NUMBER: 364816367
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2024

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, S1 Pediatric CPR/First Aid Training was completed on 03/06/2021 and there is not a current CPR/First Aid certificate on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/15/2024
	Plan of Correction
1 2 3 4	Licensee agrees to have S1 enroll or complete Pediatric CPR/First Aid Training with American Heart Association, American Red Cross, or Emergency Medical Services Authority (EMSA) approved vendor and provide proof of enrollment or completion to LPA via email by COB 07/15/2024. www.emsa.ca.gov

Type B

Section Cited

CCR

102418(a)

Immunizations

(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. C1 and C3 immunization record is missing, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/15/2024
	Plan of Correction
1 2 3 4	Licensee agrees to obtain the immunization record for C1 and C3and provide proof of completion to LPA via email by COB 07/15/2024.

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:

Aaron Ross

LICENSING EVALUATOR NAME:

Taityana Benson

LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC809 (FAS) - (06/04)

Page: 4 of 9

Document Has Been Signed on 06/27/2024 12:41 PM - It Cannot Be Edited

Created By: Taityana Benson On 06/27/2024 at 11:57 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CRISTOBAL FAMILY CHILD CARE	FACILITY NUMBER: 364816367
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(8)

Operation of A Family Child Care Home

(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, the Licensee did not meet the above regulation which poses a potential safety risk to the children in care. During the file review the LPA was unable to review a current roster upon arrival. During the inspection the Licensee updated the roster.
	POC Due Date: 07/15/2024
	Plan of Correction
1 2 3 4	Licensee understands there must be a current roster on file documenting all children enrolled and agrees to update the facility roster and provide a copy of of the facility roster to the LPA via email by COB on 07/15/2024..

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Aaron Ross

LICENSING EVALUATOR NAME:

Taityana Benson

LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC809 (FAS) - (06/04)

Page: 5 of 9

Document Has Been Signed on 06/27/2024 12:41 PM - It Cannot Be Edited

Created By: Taityana Benson On 06/27/2024 at 11:57 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CRISTOBAL FAMILY CHILD CARE	FACILITY NUMBER: 364816367
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, the Licensee did not meet the above regulation which poses a potential Health risk to the children in care. During the file review the LPA was unable to review an LIC 995 Parents Rights for C3.
	POC Due Date: 07/15/2024
	Plan of Correction
1 2 3 4	Licensee understands that all children enrolled must have an LIC 955 Parents Rights on file. Licensee agrees to obtain LIC 995 Parents Rights for C3 then submit to the Department on or by 7/152024.

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:

Aaron Ross

LICENSING EVALUATOR NAME:

Taityana Benson

LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC809 (FAS) - (06/04)

Page: 6 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CRISTOBAL FAMILY CHILD CARE	FACILITY NUMBER: 364816367
	VISIT DATE: 06/27/2024

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·Health & Safety Certificate - completed on 06/10/2000
· Fire Clearance Granted: 08/30/2005
· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

· Clean, safe and age appropriate toys

· Current roster on file
· Documentation of fire and disaster drills not on file – Last drill (date unknown)
· Children’s records are not complete
· No Employee’s Present
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

· Resident records reviewed on 06/27/2024 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

- LPA discussed the safe sleep regulations with Licensee, Agnes Cristobal 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, Agnes Cristobal 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.

Report Continued On LIC809-C

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC809 (FAS) - (06/04)

Page: 7 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CRISTOBAL FAMILY CHILD CARE	FACILITY NUMBER: 364816367
	VISIT DATE: 06/27/2024

NARRATIVE

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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: http://www.ada.gov/childqanda.htm

- Licensee, Agnes Cristobal 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.

- 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 communication platform. To receive important licensed-related information to licensed facilities, 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.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at: 951-782-4200

See LIC809-D for cited deficiencies.

LPA Taityana Benson informed Licensee, Agnes Cristobal that this report dated 06/27/2024 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Report Continued On LIC809-C

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC809 (FAS) - (06/04)

Page: 8 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CRISTOBAL FAMILY CHILD CARE	FACILITY NUMBER: 364816367
	VISIT DATE: 06/27/2024

NARRATIVE

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Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Also, LPA Taityana Benson informed the Licensee, Agnes Cristobal to provide a copy of this licensing report dated 06/27/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The Licensee, Agnes Cristobal, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the Licensee, Agnes Cristobal.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Taityana Benson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC809 (FAS) - (06/04)

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