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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700240
Report Date: 11/01/2021
Date Signed: 11/16/2021 10:23:26 AM

Document Has Been Signed on 11/16/2021 10:23 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:MEDINA FAMILY CHILD CAREFACILITY NUMBER:
367700240
ADMINISTRATOR:SONIA MEDINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 887-7576
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
11/01/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Licensee, Sonia MedinaTIME COMPLETED:
12:42 PM
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Licensing Program Analysts (LPA) Maddox met with licensee, Sonia Medina today for the purpose of conducting an announced Pre-Licensing inspection. Present today was licensee only. The licensee guided Analyst on a tour of the home indoors and outside. The home is a single-story family home with 4 bedrooms and 2.5 bathrooms. All adults in the home, license, husband, and 2 adult sons (son's do not live in the home) have fingerprint clearances and exams for T.B. The living room; 1 bathroom, kitchen/dining, office/day care area, and back yard.

Home has central heating and air conditioning. The kitchen and bathroom were toured and inspected for proper storage of chemicals, detergents, cleaning compounds, medications (locked kept in master bedroom) and sharp pointed objects, all items were made inaccessible to children. The outside play area was clear of chemicals and debris, the entire yard is fenced. There is an in-ground swimming pool located in the backyard. LPA verified the fencing is at least 5ft tall, there are 2 entry gates into the pool area, 1 gate will not be used, the main entry gate opens away from the pool and has a spring closure in place. All unused electrical outlets are plugged and play equipment and toys are available.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 367700240
VISIT DATE: 11/01/2021
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Licensee is aware that baby walkers, bouncer, or any similar equipment are prohibited in any licensed facility. Per licensee, there are no weapons or firearms of any kind on the premises. The required fire extinguisher (2A 10BC), smoke detector, and carbon monoxide devise are in operable condition. Roster and Disaster drills were discussed.

Licensee's CPR and First Aid certificates expire (2/2022) nsee can access forms online at www.ccld.ca.gov . LPA observed all required forms posted; Regulation prohibits the smoking of tobacco in any licensed facility.


The licensee is reminded of the requirement to report and unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC 624B.

The applicant is urged visit the U.S. Consumer Product Safety Commission web page at www.cpsc.gov to ensure that equipment purchased for the day care has not been recalled

Once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809/LIC9099) must also be posted for 30 days. A civil penalty of $100 per violation will be assessed for noncompliance.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 367700240
VISIT DATE: 11/01/2021
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For minor biological children: when your child(ren) turn 18 years of age, you MUST SUBMIT an updated LIC279, LIC508 and exam for TB Screen, also they must obtain a background clearance through LIVESCAN. This also applies to any adult PRIOR to them moving into the home or who currently lives in the home. Also, PRIOR to employment of any adult, you must submit the LIC508, TB screening and obtain a background clearance through LIVESCAN.

Licensee was informed of new regulations regarding Safe Sleep (102425 INFANT SAFE SLEEP) and the requirement to complete An Individual Infant Sleeping Plan [LIC 9227 (3/20)] for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.

Licensee's current email addresses are: medinafamilydaycare@gmail and

carlosandsonia@verizon.met.

LPA is requesting bumper pads be placed on the corners of the raised fire place in the living room, on the table in the dining area and smaller table in the dining area (licensee will send in pictures.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC809 (FAS) - (06/04)
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