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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629375
Report Date: 05/23/2024
Date Signed: 05/23/2024 10:50:48 AM

Document Has Been Signed on 05/23/2024 10:50 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, GLORIA ZAMAYOA FAMILY CHILD CAREFACILITY NUMBER:
376629375
ADMINISTRATOR/
DIRECTOR:		GLORIA ZAMAYOAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 743-9132
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
05/23/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Gloria Zamayoa Hernandez, ProviderTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On May 23, 2024, at 8:50 p.m., Licensing Program Analyst (LPA), D. Sanchez, conducted an unannounced Annual Random Inspection and met with the Licensee, Gloria Zamayoa Hernandez. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. Five (5) children and one (1) staff and provider were present in the facility during this inspection. This facility is a single story, three bedroom, two bathroom house. Licensee accompanied LPA inside and out of the facility during this inspection. The following areas used for child care are: living room, dining room, family room, hallway bathroom, bedroom located next to the living room, side and back yard. Off limits areas are: all bedrooms, master bathroom and garage and are inaccessible through use of door knob protection and baby gate.

The fire extinguisher, smoke detector, and carbon monoxide detector met requirements. All hazardous items were inaccessible to children. The storage area for poisons is locked. The licensee has toys, play equipment and materials available. The home has a fenced back and side yard and available for outdoor activities. No bodies of water observed on the premises during the inspection. Licensee stated there are no weapons in the home. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Licensee’s First Aid and CPR certifications expire on 9/2025. Licensee has required immunizations, but could not provide proof of staff #1 immunization record and employee rights form. Licensee completed Mandated Reporter Training on 06/14/2022. Facility roster is maintained and was reviewed. The last fire and disaster drills were conducted and documented on 04/2024.

There is one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards are free from all loose articles and objects. The provider physically checks on sleeping infants every 15 minutes. An Individual Infant Sleeping Plan [LIC 9227 (3/20)] is maintained for each infant up to 12 months of age. The provider places infants up to 12 months of age on their backs for sleeping.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Diana Sanchez
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: HERNANDEZ, GLORIA ZAMAYOA FAMILY CHILD CARE
FACILITY NUMBER: 376629375
VISIT DATE: 05/23/2024
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LPA provided and discussed the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, and ensure that all adults residing or working in the home have criminal background clearances or exemptions. Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare. Licensee was also provided handouts with information regarding upcoming Safe Sleep Regulations/SIDS, Lead exposure and Shaken Baby Syndrome. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA discussed and provided Licensee with the following: child care advocates email address: childcareadvocatesprogram@dss.ca.gov . In addition, for general questions or questions regarding licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.

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.

California Code of Regulations, (Title 22, Division 12 & Chapter 3), are being cited on the attached LIC 809-D.

An exit interview was conducted with the licensee. The 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: Jason Garay
LICENSING EVALUATOR NAME: Diana Sanchez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2024 10:50 AM - It Cannot Be Edited


Created By: Diana Sanchez On 05/23/2024 at 10:18 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: HERNANDEZ, GLORIA ZAMAYOA FAMILY CHILD CARE
FACILITY NUMBER: 376629375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

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 in not having employee record and the required form LIC9052 on staff #1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee Gloria Zamayoa stated that she will ensure to maintain a folder with all required documents for staff #1. She will send copies of employee's record to the San Diego Child Care Regional Office (SDCCRO).
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 in not being able to provide proof of immunization on staff #1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee Gloria Zamayoa stated that she will ensure to take staff #1 to obtain all required immunizations and will send copies to the SDCCRO by the due date of 5/31/2024.
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:Jason Garay
LICENSING EVALUATOR NAME:Diana Sanchez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024


LIC809 (FAS) - (06/04)
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