<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393622766
Report Date: 10/27/2021
Date Signed: 10/27/2021 02:53:33 PM

Document Has Been Signed on 10/27/2021 02:53 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:PENA, NORMAFACILITY NUMBER:
393622766
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
10/27/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Norma PenaTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/27/21 Licensing Program Analyst (LPA) Aruna Sridharan met with licensee Norma Pena for unannounced annual inspection. LPA followed infection control protocols. The hours of operation are 7:00am to 5:30pm Monday through Friday.

The family child care home facility is two story family home with four bedrooms, two bathrooms, living room, kitchen and garage. Today's census is 3 children including 1 infant and 2 preschoolers. Off limit areas: entire upstairs and garage. Licensee acknowledges that children may never enter these off-limit areas. The backyard is fenced where children's outdoor play area is set up. Licensee was notified that prior to use of any off limit areas, the department must be notified.

A tour of the home, inside and outside, as shown on the facility sketch was conducted. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. The first aid kit and medications are kept in upper shelf in the pantry Fire extinguisher is next to fridge in the kitchen counter and cleaning compounds are stored in upper shelf in the pantry. LPA observed firearms locked separately.
Safe toys and play equipment are observed. LPA observed all the required postings, reviewed licensee's records and all 3 childrens records. Licensee did not provide proof of immunizations, CPR/First aid and Mandated Reporter certifications. This is a potential risk to health and safety of children in care. Type B deficiencies are cited.
Licensee did not have a children's roster and no documentation of fire drill log. These are potential risks to the health and safety of children and so the Type B deficiencies are cited.
LPA discussed the Safe Sleep regulations.

LPA advised the facility to follow all the Covid precautions while providing care for children.
Report continues on 809C page...
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: PENA, NORMA
FACILITY NUMBER: 393622766
VISIT DATE: 10/27/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This facility does not provide Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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/process.

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.

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 [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.

Title 22 Deficiencies observed in the areas of today's facility evaluation are on page 809D. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee.

SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/27/2021 02:53 PM - It Cannot Be Edited


Created By: Aruna Sridharan On 10/27/2021 at 01:42 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: PENA, NORMA
FACILITY NUMBER: 393622766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not documenting fire drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
1
2
3
4
Licensee will submit a documentation of fire drill to LPA by POC 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:Justin L Denton
LICENSING EVALUATOR NAME:Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/27/2021 02:53 PM - It Cannot Be Edited


Created By: Aruna Sridharan On 10/27/2021 at 01:42 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: PENA, NORMA
FACILITY NUMBER: 393622766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not having valid Mandated Reporter certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2021
Plan of Correction
1
2
3
4
Licensee will send the AB 1207 certification to LPA by POC date.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having proof of immunizations for herself and TB shot record for other resident adults which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2021
Plan of Correction
1
2
3
4
Licensee will send proof of immunizations to LPA by POC 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:Justin L Denton
LICENSING EVALUATOR NAME:Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/27/2021 02:53 PM - It Cannot Be Edited


Created By: Aruna Sridharan On 10/27/2021 at 02:03 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: PENA, NORMA
FACILITY NUMBER: 393622766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

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: (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
1
2
3
4
Based on LPA's observation, the licensee did not comply with the section cited above by keeping comet and lighter fluid accessible to children in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
1
2
3
4
Licensee removed the items and placed it away inaccessible to children.
Type A
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: (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
1
2
3
4
Based on LPA's observation, the licensee did not comply with the section cited above by having baby saucer in the facility. Licensee admitted to using the saucer on parent's request which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
1
2
3
4
Licensee removed the saucer and put it in offlimits. Licensee will return it to the parent today.
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:Justin L Denton
LICENSING EVALUATOR NAME:Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/27/2021 02:53 PM - It Cannot Be Edited


Created By: Aruna Sridharan On 10/27/2021 at 02:03 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: PENA, NORMA
FACILITY NUMBER: 393622766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not haveing current roster which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
1
2
3
4
The licensee will send an updated roster to LPA by POC date.
Type B
Section Cited
CCR
102416.2(a)(2)
Reporting Requirements
(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (2) Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above by stating that her adult daughter is living in the home which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
1
2
3
4
The licensee will update the Application and send it to LPA by POC 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:Justin L Denton
LICENSING EVALUATOR NAME:Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
Page: 6 of 6