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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629129
Report Date: 08/30/2021
Date Signed: 08/30/2021 03:54:39 PM

Document Has Been Signed on 08/30/2021 03:54 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:THEANO, CELINE FAMILY CHILD CAREFACILITY NUMBER:
376629129
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
08/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Stephani GalindoTIME COMPLETED:
04:00 PM
NARRATIVE
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On August 30, 2021 at 1:35pm, Licensing Program Analysts (LPAs), David Miller and Martha Malane conducted an unannounced case management inspection. Upon arrival, LPAs met with licensee’s helpers Stephanie Galindo and Alexa Alcantar and disclosed the purpose of the inspection and were led on a tour. There was one (1) infant child and one (1) two-year-old child napping during the inspection. Facility operates Monday through Friday from 8:00am to 5:00pm.

California Code of Regulations, (Title 22, Division 12 & Chapter 3), are being cited on the attached LIC809D pages.

Upon Receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

An exit interview was conducted with the licensee. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.

LPA provided notice of site visit and observed it being posted at the facility.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
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 3
Document Has Been Signed on 08/30/2021 03:54 PM - It Cannot Be Edited


Created By: Martha Malane On 08/30/2021 at 02:28 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: THEANO, CELINE FAMILY CHILD CARE
FACILITY NUMBER: 376629129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2021
Section Cited
CCR
102370(d)(2)

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102370(d)(2)Criminal Background Clearance(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working... in a licensed facility:
Obtain a California clearance...(2) Request a transfer of a criminal record clearance this requirement was not met as evidenced by:
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Transfer request was sent to CCL during today's inspection 8/30/2021.
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Based on records review and licensee's admission, licensee did not ensure H1 had a criminal record transfer prior to working, residing, or volunteering in a licensed facility as required, which poses an immediate Health and Safety risk to the children in care.
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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:Tulam Vu
LICENSING EVALUATOR NAME:Martha Malane
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/30/2021 03:54 PM - It Cannot Be Edited


Created By: Martha Malane On 08/30/2021 at 03:01 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: THEANO, CELINE FAMILY CHILD CARE
FACILITY NUMBER: 376629129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited
HSC
1597.622(a)(1)

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1597.622(a)(1)Immunization Requirements…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. This requirement was not met as evidence by:
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Licensee will provide proof of immunization records for H1 to CCL no later than 9/7/2021.
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Based on Immunization records not available for review during the time of inspection, it was determined immunization records for H1 were not available at the facility. This poses a potential health and safety risk to children in care.
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Type B
09/03/2021
Section Cited
HSC102416(c)

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102416(c) Personnel Requirements (c)The licensee and other personnel as specified shall complete training on... pediatric cardiopulmonary resuscitation and pediatric first aid this requirement was not met as evidenced by:
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Licensee stated she will send a plan to CCL ensuring there is always at least one personnel with an approved and current CPR/FA Card by 9/7/2021.
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Based on records review and licensee's admission, licensee did not ensure there was at least one personnel at the facility with an approved and current CPR/FA card.
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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:Tulam Vu
LICENSING EVALUATOR NAME:Martha Malane
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2021


LIC809 (FAS) - (06/04)
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