376620714-10-23-2023-20-CC-JARL-CWVNAK-20231023101738

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376620714
Report Date: 10/23/2023
Date Signed: 10/23/2023 10:17:43 AM

Document Has Been Signed on 10/23/2023 10:17 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	HERNANDEZ, MARTHA & JOSE FAMILY CHILD CARE		FACILITY NUMBER:	376620714
ADMINISTRATOR:	MARTHA & JOSE HERNANDEZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(619) 850-3610
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92105
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 6	DATE:	10/23/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Martha & Jose Hernandez		TIME COMPLETED:	10:00 AM

NARRATIVE

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On 10/23/2023, at 9:25 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted a case management inspection to follow-up on an incident that occurred on 10/18/2023. LPA advised Licensees Martha and Jose Hernandez of the meeting’s purpose and was granted facility entry. Licensees provided LPA with a facility tour. There were six (6) children present in the facility with both Licensees and two (2) helpers. The children’s ages were 20 months to 3.5 years.

A child sustained an injury and required medical examination on 10/18/2023. The incident was self-reported by the facility and a written report was received in the Licensing office within the required reporting period. There were 14 children with both licensees during the incident; younger children were with Licensee Martha Hernandez in the facility’s “California Room”, while older children and the involved child were in the living room, which has a hard wood floor. The involved child was in the living room because they were to be retrieved by their parent. On 10/18/2023, at about 1:20 PM, the child fell face forward onto the living room floor from their chair. The child bit their tongue. Licensees contacted the parent and paramedics. Paramedics transported the child to the hospital. LPA inspected the living room chair, living room and kitchen. LPA also interviewed children, parent, staff and the licensees.

LPA provided Licensees with CCR 102417(a) and the “Active Supervision At A Glance” handout provided by the Early Childhood National Centers. Licensees said they will provide the Department with their written statement detailing which steps they will take to ensure similar like incidents do not occur recur and how young children shall use age-appropriate furniture. The Licensees agreed to provide the Department with these written statements by 10/30/2023. No citations given.

A notice of site visit was given to licensees and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview was conducted and the report was reviewed with the Licensees Martha and Jose Hernandez.

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

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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