364840224-7-2-2025-09-CC-TBEN-DJ7R8W-20250702124837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364840224
Report Date: 07/02/2025
Date Signed: 07/02/2025 12:49:09 PM

Document Has Been Signed on 07/02/2025 12:49 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:	CALVA FAMILY CHILD CARE		FACILITY NUMBER:	364840224
ADMINISTRATOR/ DIRECTOR:	EVARISTA CALVA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(909) 362-5046
CITY:	HIGHLAND	STATE: CA	ZIP CODE:	92346
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 10	CENSUS: 6	DATE:	07/02/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:53 AM
MET WITH:	Evarista Calva, Licensee		TIME VISIT/ INSPECTION COMPLETED:	01:00 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	On date and time listed, Licensing Program Analysts (LPAs) Taityana Benson and Perla Ordonez arrived at the facility to conduct an annual inspection as part of a compliance review. LPAs were granted entry into the facility by Parris Avila who identified themselves as Day Care Assistant. Licensee Evarista Calva arrived at the facility at 9:06 a.m. LPAs 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. – 11:30 p.m. OFF-LIMIT AREAS INCLUDE: Entire 2^nd Floor Tool House, Storage, 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. · Fireplace is properly screened to prevent access by children. · All hazardous items are stored inaccessible to children. · Toxins are locked. Report Continued On LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Aaron Ross
NAME OF LICENSING PROGRAM ANALYST: Taityana Benson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 07/02/2025 12:49 PM - It Cannot Be Edited

Created By: Taityana Benson On 07/02/2025 at 11:13 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: CALVA FAMILY CHILD CARE	FACILITY NUMBER: 364840224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1596.871(c)(1)(A)

Administration of Child Day Care Licensing

Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review and interviews the facility did not comply with the section cited above as LPA observed one staff member present during the visit, engaging with the day care children and the staff member is not associated to the facility. The staff member date of employment is 07/02/2025, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/03/2025
	Plan of Correction
1 2 3 4	Licensee agrees that the uncleared staff member will not return to the facility until they have a criminal record clearance. Licensee agrees to provide proof of a completed LIC9163 for the uncleared staff member to Community Care Licensing by the end of the business day on the POC due date of 07/03/2025. A civil penalty of $100.00 per day is assessed, totaling $100.00.

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.

	Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:

	Taityana Benson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

Page: 3 of 13

Document Has Been Signed on 07/02/2025 12:49 PM - It Cannot Be Edited

Created By: Taityana Benson On 07/02/2025 at 11:13 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: CALVA FAMILY CHILD CARE	FACILITY NUMBER: 364840224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(4)(C)

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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (C) Ammunition shall be stored and locked separately from firearms. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above, a firearm and ammunition were observed in a locked box together, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2025
	Plan of Correction
1 2 3 4	During the visit, LPA observed the licensee spouse lock the firearm and ammunition separately. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations.

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.

	Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:

	Taityana Benson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

Page: 4 of 13

Document Has Been Signed on 07/02/2025 12:49 PM - It Cannot Be Edited

Created By: Taityana Benson On 07/02/2025 at 11:13 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: CALVA FAMILY CHILD CARE	FACILITY NUMBER: 364840224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)1

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. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home. 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. During the visit, the licensee stated the last fire/disaster drill was conducted on 03/25/2024, but the date of the fire/disaster drill was not documented on the fire/disaster drill log. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee agrees to document the last fire/disaster drill that includes the date and time on the fire/disaster drill log and provide proof to Community Care Licensing by the end of the business day on the POC due date of 07/16/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:

	Taityana Benson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/02/2025 12:49 PM - It Cannot Be Edited

Created By: Taityana Benson On 07/02/2025 at 11:13 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: CALVA FAMILY CHILD CARE	FACILITY NUMBER: 364840224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2025

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 and observation, the licensee did not comply with the section cited above. Staff Member (S3) was present with day-care children in care alone upon LPAs arrival. S3 does not have a current Pediatric CPR/First Aid certificate on file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee agrees to obtain proof of S3 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 Community Care Licensing by the end of the business day on the POC due date of 07/16/2025.

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Staff 1 (S1) proof of required MMR, S2 and S3: MMR, Pertussis, Influenza, immunization's are not available for review during this visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee agrees to obtain proof of S1, S2 and S3 required immunization's and maintain proof at the facility. Licensee agrees to provide proof of S1, S2 and S3 MMR, Pertussis, Influenza required immunization'ss to Community Care Licensing by the end of the business day on the POC due date of 07/16/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:

	Taityana Benson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

Page: 6 of 13

Document Has Been Signed on 07/02/2025 12:49 PM - It Cannot Be Edited

Created By: Taityana Benson On 07/02/2025 at 11:13 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: CALVA FAMILY CHILD CARE	FACILITY NUMBER: 364840224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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. Child 3, Child 5, and Child C6 (C3, C5, and C6) proof of required immunizations are not on file, nor available for review during this visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee agrees to obtain and maintain proof of C3, C5, and C6 required immunizations. Licensee agrees to provide proof of C3, C5, and C6 required immunizations to Community Care Licensing by the end of the business day on the POC due date of 07/16/2025.

Type B

Section Cited

CCR

102421(c)

Child's Records

(c) In any case in which the licensee cares for an additional child pursuant to Section 102416.5(b) for a Small Family Child Care Home or Section 102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child’s record, a copy of documentation verifying the child’s enrollment and attendance at kindergarten, including transitional kindergarten, or elementary school as required in Section 102416.5(g). 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. Child 6 (C6) Parent Notification Additional Children In Care (LIC9150) is not available for review during this visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee agrees to have C6’s authorized representative complete form Parent Notification Additional Children In Care (LIC9150) and maintain proof at the facility. Licensee agrees to provide proof of C6’s Parent Notification Additional Children In Care (LIC9150) to Community Care Licensing by the end of the business day on the POC due date of 07/16/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:

	Taityana Benson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

Page: 7 of 13

Document Has Been Signed on 07/02/2025 12:49 PM - It Cannot Be Edited

Created By: Taityana Benson On 07/02/2025 at 11:13 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: CALVA FAMILY CHILD CARE	FACILITY NUMBER: 364840224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. 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. Child 6 (C6) Identification and Emergency Information (LIC700) and Consent for Emergency Medical Treatment (LIC627), not available for review during this visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee agrees to have C6’s authorized representative complete form Identification and Emergency Information (LIC700) and Consent for Emergency Medical Treatment (LIC627) and maintain proof at the facility. Licensee agrees to provide proof of C6’s Identification and Emergency Information (LIC700) and Consent for Emergency Medical Treatment (LIC627) to Community Care Licensing by the end of the business day on the POC due date of 07/16/2025.

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 record review, the licensee did not comply with the section cited above. The Child Care Facility Roster (LIC9040) is incomplete during this visit, with the licensees own admission, there are 10 children enrolled and the Child Care Facility Roster list 09 children enrolled, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee agrees to complete and maintain the Child Care Facility Roster with currently enrolled children. Licensee agrees to provide a copy of the Child Care Facility Roster to Community Care Licensing by the end of the business day on the POC due date of 07/16/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:

	Taityana Benson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

Page: 8 of 13

Document Has Been Signed on 07/02/2025 12:49 PM - It Cannot Be Edited

Created By: Taityana Benson On 07/02/2025 at 11:13 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: CALVA FAMILY CHILD CARE	FACILITY NUMBER: 364840224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2025

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 record review, the licensee did not comply with the section cited above. Child 6 (C6) Notification of Parents’ Rights (LIC995A) is not available for review during this visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee agrees to have C6’s authorized representative complete form Notification of Parents’ Rights (LIC995A) and maintain proof at the facility. Licensee agrees to provide proof of C6’s Notification of Parents’ Rights (LIC995A) to Community Care Licensing by the end of the business day on the POC due date of 07/16/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:

	Taityana Benson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

Page: 9 of 13

Document Has Been Signed on 07/02/2025 12:49 PM - It Cannot Be Edited

Created By: Taityana Benson On 07/02/2025 at 11:13 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: CALVA FAMILY CHILD CARE	FACILITY NUMBER: 364840224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(m)(3)

Operation of A Family Child Care Home

(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. 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. Child 6 (C6) Affidavit Regarding Liability Insurance (LIC282), is not available for review during this visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee agrees to have C6’s authorized representative complete form Affidavit Regarding Liability Insurance (LIC282) and maintain proof at the facility. Licensee agrees to provide proof of C6’s Affidavit Regarding Liability Insurance (LIC282) to Community Care Licensing by the end of the business day on the POC due date of 07/16/2025.

Type B

Section Cited

CCR

102369(b)(9)

Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care. 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. Staff (S3) proof of tuberculosis test results are not available for review during this visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee agrees to obtain and maintain proof of S3’s tuberculosis test results. Licensee agrees to provide proof of S3’s tuberculosis test results to Community Care Licensing by the end of the business day on the POC due date of 07/16/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:

	Taityana Benson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

Page: 10 of 13

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: CALVA FAMILY CHILD CARE	FACILITY NUMBER: 364840224
	VISIT DATE: 07/02/2025

NARRATIVE

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·Weapons were not stored according to Licensee Evarista Calva. 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.
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted.
· Mandated Reporter Training completed on 01/18/2024.
· Pediatric CPR and First Aid Card expires on 04/26/2024.
· Health & Safety Certificate - completed on 09/09/2020.
· 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 not on file (See LIC809-D).
· Documentation of fire and disaster drills on file – Last drill conducted on 03/25/2024 (See LIC809-D).
· Children’s records are not complete (See LIC809-D).
· Employee’s records are not complete (See LIC809-D).

· 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 and/or staff records reviewed on 07/02/2025 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

Report Continued LI809-C

NAME OF LICENSING PROGRAM MANAGER: Aaron Ross
NAME OF LICENSING PROGRAM ANALYST: Taityana Benson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

Page: 11 of 13

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: CALVA FAMILY CHILD CARE	FACILITY NUMBER: 364840224
	VISIT DATE: 07/02/2025

NARRATIVE

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LPA discussed the safe sleep regulations with Licensee Evarista Calva, provided a copy of the safe sleep regulations, and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed Licensee Bertha Guerrero 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.

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: https://www.ada.gov/resources/child-care-centers/

Licensee Evarista Calva was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Licensee Evarista Calva was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Report Continued On LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Aaron Ross
NAME OF LICENSING PROGRAM ANALYST: Taityana Benson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

Page: 12 of 13

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: CALVA FAMILY CHILD CARE	FACILITY NUMBER: 364840224
	VISIT DATE: 07/02/2025

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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 for deficiencies.

LPA Taityana Benson informed Licensee Evarista Calva that this report dated 07/02/2025 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.

Also, LPA Taityana Benson informed the Licensee Evarista Calva to provide a copy of this licensing report dated 07/02/2025 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.

A notice of site visit was given and must remain posted for 30 days.

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

During the exit interview, the Licensee Evarista Calva confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

NAME OF LICENSING PROGRAM MANAGER: Aaron Ross
NAME OF LICENSING PROGRAM ANALYST: Taityana Benson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

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