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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376620000
Report Date: 07/29/2022
Date Signed: 07/29/2022 02:09:46 PM

Document Has Been Signed on 07/29/2022 02:09 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CRUZ, GUADALUPE & GONZALEZ, MATILDE FCCFACILITY NUMBER:
376620000
ADMINISTRATOR:GUADALUPE C. & MATILDE G.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 249-0539
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Guadalupe CruzTIME COMPLETED:
02:30 PM
NARRATIVE
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On 7/29/2022 at 8:30am, Licensing Program Analysts (LPAs), Saraliz Velando and Adrian Mangina conducted an unannounced Annual Licensing Inspection. LPAs were greeted at the front door by Guadalupe Cruz and granted entry after identifying themselves and disclosing the purpose of their visit. Also present in the home was licensee Matilde Gonzalez and 10 daycare children. Proper ratios and supervision were observed. The licensees are using the following areas for daycare: Bedroom 3, Living room, Dining room, small dining room, kitchen, bathroom 2, and backyard. Off limit areas include: Front yard, Master bedroom, bedroom 2, bathroom 1, and Garage. Business Hours are Monday-Friday, 7:30am-5:30pm. The facility currently has 10 children in care of which 3 were infants.

LPAs tested the smoke alarm in the living room and carbon monoxide alarm the located in the dining room area. Both devices were functional. LPAs observed the fire extinguisher was classification 3-A-40-BC which meets regulations. LPAs observed loose fitting sheets in 2 pack and plays in bedroom 3 and 1 in the living room. LPAs observed an exersaucer in the living room. In addition, toys and blankets were found within. LPAs advised licensee that pack and plays must have tight fitting sheets and no toys and blankets allowed per Safe Sleep regulations. Licensee was advised to follow all Safe Sleep regulations. Licensees left infants in high chairs for over 20 minutes and used the high chairs two times for supervision from 9:30am to 9:52am and again from 12:15pm to 1:00pm, far beyond the end of meal time. Children were not checked on during those times, while licensees were conducting lesson plans and doing chores.

Fireplace in living room was screened to prevent access by children. Storage for poisons, detergents, cleaning solutions, medications are stored high and with use of doorknob covers have been made inaccessible to children. Outdoor play area was fenced and LPAs observed several furrows in dirt of the accessible backyard and 3 toys and easel that were dirty, rusty, and broken in the play area. Licensee states she ran out of room on disaster drill form and threw it away.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Saraliz Velando
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
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 07/29/2022 02:09 PM - It Cannot Be Edited


Created By: Saraliz Velando On 07/29/2022 at 11:51 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CRUZ, GUADALUPE & GONZALEZ, MATILDE FCC
FACILITY NUMBER: 376620000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022

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
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Based on observation, the licensee did not comply with the section cited above as the accessible backyard has several furrows in th dirt area creating a tripping hazard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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Licensee states she will fill in furrows and provide proof to LPA by 8/29/22.
Type B
Section Cited
CCR
102417(g)(10)
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: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

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 as licensee has an exersaucer in the living room area that is used for children in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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Licensee removed the exersaucer while LPAs were present and stated that in the future she will not use prohibited items in the facility.
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:Monica Cuddy
LICENSING EVALUATOR NAME:Saraliz Velando
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/29/2022 02:09 PM - It Cannot Be Edited


Created By: Saraliz Velando On 07/29/2022 at 11:51 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CRUZ, GUADALUPE & GONZALEZ, MATILDE FCC
FACILITY NUMBER: 376620000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 as licensees state they do not have Mandated Reporter Certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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Licensees state that they will complete the Mandated Reporter training and provide proof to LPA no later than 8/29/22.
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
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Based on interview and record review, the licensee did not comply with the section cited above as licensees state they do not have CPR/First Aid for pediatric and infant, cards or certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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Licensees state that they will complete the CPR/First Aid pediatric and infant training and provide proof to LPA no later than 8/29/22.
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:Monica Cuddy
LICENSING EVALUATOR NAME:Saraliz Velando
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022


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Document Has Been Signed on 07/29/2022 02:09 PM - It Cannot Be Edited


Created By: Saraliz Velando On 07/29/2022 at 11:51 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CRUZ, GUADALUPE & GONZALEZ, MATILDE FCC
FACILITY NUMBER: 376620000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022

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
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Based on interview and record review, the licensee did not comply with the section cited above as licensee stated she does not keep a child roster which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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Licensees stated that they will complete a current roster and provide proof to LPA no later than 8/29/22.
Type B
Section Cited
CCR
102423(a)(1)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (1) To be treated with dignity in his/her personal relationship with staff and other persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensees did not comply with the section cited above as infant was placed in a high chair for more than 20 minutes while licensee was providing lesson plan and as a substitute for adequate supervision which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2022
Plan of Correction
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Licensees stated that they will remove the children from the high chair when they are finished eating.
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:Monica Cuddy
LICENSING EVALUATOR NAME:Saraliz Velando
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022


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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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CRUZ, GUADALUPE & GONZALEZ, MATILDE FCC
FACILITY NUMBER: 376620000
VISIT DATE: 07/29/2022
NARRATIVE
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Licensee states she had last drill on 7/21/22 at 3pm. Licensee was reminded to keep facility records for 3 years. LPA reminded licensee to add a second relocation site to the LIC610A. The home is kept clean and orderly with heating and ventilation for safety and comfort. The home provides safe toys, play equipment and materials.

LPAs reviewed 10 children’s records and observed Child 1 and 2-No Immunization record, Child 3, 4,5, 6, 8,9,and 10- Immunization record not on blue paper, Child 1 and 7 missing LIC9150, Child 6 and 7 missing LIC282, Child 6 missing LIC995A, Child 4 and 9 - LIC700 unsigned, Child 4 LIC282 incomplete. Licensee states she does not keep a child roster. LPA advised Licensee that roster must be kept up to date at all times. Licensees state do not have current CPR/First Aid certificates and mentioned they expired and were thrown away. Licensees stated they do not keep personnel files for themselves. LPAs advised licensees must keep a file for herself and the other licensee. Licensees do not have current Mandated Reporter AB1207 on file. There is a working telephone and email address.

Licensee or facility representative was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain 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.

LPA discussed the safe sleep regulations with licensee or facility representative 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 for 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.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Saraliz Velando
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
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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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CRUZ, GUADALUPE & GONZALEZ, MATILDE FCC
FACILITY NUMBER: 376620000
VISIT DATE: 07/29/2022
NARRATIVE
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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.

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/inspection-process.

Based on today’s visit, deficiencies were observed and noted on the attached LIC 809D. See LIC9102s for technical violations given.

Exit interview conducted and report was reviewed with the licensees, Guadalupe Cruz and Matilde Gonzalez. 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.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Saraliz Velando
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/29/2022 02:09 PM - It Cannot Be Edited


Created By: Saraliz Velando On 07/29/2022 at 01:46 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CRUZ, GUADALUPE & GONZALEZ, MATILDE FCC
FACILITY NUMBER: 376620000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement was not met as evidenced by:


Deficient Practice Statement
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Based on record review, 9 out 10 children’s files were not complete which poses a potential health, safety, or personal rights risk to children in care.
POC Due Date: 08/29/2022
Plan of Correction
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Licensee states she will provide complete files to LPA for all in children in care no later than 8/29/22.
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:Monica Cuddy
LICENSING EVALUATOR NAME:Saraliz Velando
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022


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