364818501-6-14-2024-09-CC-RZEN-D68PT9-20240614113533

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364818501
Report Date: 06/13/2024
Date Signed: 06/14/2024 11:36:07 AM

Document Has Been Signed on 06/14/2024 11:36 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	PEREZ FAMILY CHILD CARE		FACILITY NUMBER:	364818501
ADMINISTRATOR/ DIRECTOR:	DOLORES PEREZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(909) 628-9819
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 9	CENSUS: 4	DATE:	06/13/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Dolores Perez		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Rachel Zeron and Office Technician(OT) and translator, Eric Ramos arrived at the facility to conduct an annual inspection as part of a compliance review. The facility is currently on a Non compliance plan for 24 months, expiring on 12/05/2025. LPA or OT 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 6:00am - 6:00pm

· Off-limit areas include: Garage, Master and middle bedroom, there is another small house and a travel trailer on the property that are currently not in use. LPA and OT inspected all areas as required, to verify there are no uncleared adults on premises

· The facility is operating within the licensed capacity and appropriate ratios

· Appropriate supervision provided during this inspection

· A working telephone is present and the current number

· 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. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

· Clean, safe and age appropriate toys

· Current roster on file

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Rachel Zeron
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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 4

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: PEREZ FAMILY CHILD CARE	FACILITY NUMBER: 364818501
	VISIT DATE: 06/13/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

·Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted

· Documentation of fire and disaster drills on file – Last drill conducted on 01/04/2024

· 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.

· Verification of control of property on file

· Children’s records are complete

· Employee’s records are complete

· Licensee’s Mandated Reporter Training expires on 12/2025

· Licensee’s Pediatric CPR and First Aid Card expires on 12/2025

· Licensee’s Health & Safety Certificate - completed on 12/20/2023

· Resident and/or staff records were reviewed and all adults who require caregiver background checks have received all required clearances and/or exemptions.

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

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

The Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Rachel Zeron
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PEREZ FAMILY CHILD CARE	FACILITY NUMBER: 364818501
	VISIT DATE: 06/13/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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

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.

Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.

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.

See LIC809-D for cited deficiencies.

An exit interview was conducted by Eric Ramos who translated per Licensee's request, and this report was reviewed with the licensee, Dolores Perez. Appeal rights were discussed and provided during the exit interview. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Rachel Zeron
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 06/14/2024 11:36 AM - It Cannot Be Edited

Created By: Rachel Zeron On 06/13/2024 at 11:28 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: PEREZ FAMILY CHILD CARE	FACILITY NUMBER: 364818501
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check 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 in 1 out of 1 infant in care, which poses a potential health, safety risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee agrees to create a sleep log for the infant in care and record sleep times, checking every 15 minutes. Licensee will send a copy of the sleep log on POC date 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:

Rachel Zeron

LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4