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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376300341
Report Date: 09/13/2022
Date Signed: 09/13/2022 01:42:09 PM

Document Has Been Signed on 09/13/2022 01:42 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
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:GU FAMILY CHILDCAREFACILITY NUMBER:
376300341
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Xia Gu, LicenseeTIME COMPLETED:
02:00 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst's (LPA's) Linda Almaraz and James Wilkerson arrived at the facility to conduct an annual inspection as part of a compliance review and for a capacity increase from 8 children to 14 children. Fire clearance was received on 9/2/2022. LPA's toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:

· Normal days and hours of operation are: 7AM-5PM
· Off-limit areas include: Garage, all second floor, and second back part of backyard.
· The facility is licensed to have no more than 8 children as a small FCCH and is operating within the licensed capacity and appropriate ratios.
· Appropriate supervision provided during this inspection
· A working telephone is present, and the current phone number is on file
· A fully charged fire extinguisher (2A:10BC) was observed. A smoke detector and carbon monoxide detector were present and tested by the Licensee during this inspection
· This facility does not have a Fireplace
· All hazardous items are not stored inaccessible to children
· Toxins were not locked
· Weapons are not present. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Stairs are barricaded
· Toys are not clean and safe
· Current roster on file
· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted (Continued on an LIC 809-C)
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
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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Document Has Been Signed on 09/13/2022 01:42 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/13/2022 at 01:10 PM
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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GU FAMILY CHILDCARE
FACILITY NUMBER: 376300341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above
by having a cleaning lysol liquid next to the toliet in the childrens restroom, a gas container with gasoline in the backyard for toilet, cough syrup and knives unlocked in the kitchen cabinet, and having the garage unlocked with hazardous items like cleaning solutions and stacked boxes and trash which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2022
Plan of Correction
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Licensee will remove all cleaning solutions, knives, and cough medicine, and lock it where its inaccesible to the children. Licensee will ensure the garage remains locked at all times and removes the gas container with gas from the back yard and makes it inaccesible to the children. Proof of correction will be sent to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2022 01:42 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/13/2022 at 01:10 PM
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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GU FAMILY CHILDCARE
FACILITY NUMBER: 376300341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having dirty toys with spider webs and spiders, and play tables with dirty water in them which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee will clean all toys and empty out the water from the play tables and put it upside down when not in use. Proof of correction will be sent to LPA via email by POC due date.
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
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Based on interview and record review, the licensee did not comply with the section cited above by not conducting a fire drills at the home which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee will conduct a fire drill with the children by POC due date and will ensure the drills are completed atleast every 6 months. Proof of completion will be send to LPA via email by POC due date.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2022 01:42 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/13/2022 at 01:10 PM
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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GU FAMILY CHILDCARE
FACILITY NUMBER: 376300341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not having a log of 15 minute checks for the infant in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee will conduct 15 minute checks on infants and document them. Licensee will start to conduct the checks immediately for the infant in care and send proof to LPA via email by POC due date.
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not having files for herself and her husband who provide care for the children.
which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Licensee will obtained and maintain a full complete file for herself and her husband. Licensee will send complete files to LPA via email by POC due date
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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2022 01:42 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/13/2022 at 01:10 PM
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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GU FAMILY CHILDCARE
FACILITY NUMBER: 376300341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022

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
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Based on interview and record review, the licensee did not comply with the section cited above by not having an emergency card for each child receiving care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee will obtain and emergency information card for each child in care. Licensee will ensure each child has a complete file with all forms required. Licensee will an LIC 700 for each child in care by POC due date.
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
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Based on interview and record review, the licensee did not comply with the section cited above by not having immunization records for the children in care in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee will obtain immunization records all children in care and any future children. Licensee will send proof of immunization for the current children enrolled bu POC due date.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2022 01:42 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/13/2022 at 01:10 PM
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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GU FAMILY CHILDCARE
FACILITY NUMBER: 376300341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not having a sleeping plan for the infant in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee will complete a sleeping plan for the infant in care with the parent and send proof of correction to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Carlos Martinez
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022


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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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GU FAMILY CHILDCARE
FACILITY NUMBER: 376300341
VISIT DATE: 09/13/2022
NARRATIVE
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· Documentation of fire and disaster drills were not file
· 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
· Mandated Reporter Training completed/expired on 1/9/2023
· Pediatric CPR and First Aid Card expire on 1/9/2023
· Health & Safety Certificate - completed on 1/31/21
· 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: UnusualIncidentReportsDO10@dss.ca.gov


(Continued on an LIC809-C)
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
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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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GU FAMILY CHILDCARE
FACILITY NUMBER: 376300341
VISIT DATE: 09/13/2022
NARRATIVE
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The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@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 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.

See LIC809-D for cited deficiencies. The capacity increase is not being granted today until the deficiencies are corrected.



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.

An exit interview was conducted, and this report was reviewed with the licensee. 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: Carlos Martinez
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
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