393622766-6-22-2022-53-CC-SMAY-CFMNBQ-20220622101931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 393622766
Report Date: 06/22/2022
Date Signed: 06/22/2022 10:19:46 AM

Document Has Been Signed on 06/22/2022 10:19 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME:	PENA, NORMA		FACILITY NUMBER:	393622766
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 1	DATE:	06/22/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Norma Pena		TIME COMPLETED:	10:30 AM

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	Licensing Program Analysts (LPAs) Salene Mayberry and Christopher Jackson met with Licensee, Norma Pena for the purpose of conducting a case management inspection to increase the facility capacity from a Small to a Large Family Child Care Home. A fire clearance was granted by Stockton Fire Prevention on 6/20/2022. LPAs observed 1 child present in the home with Licensee and her Assistant. The hours of operation are 7:00 am to 5:30 pm Monday through Friday. All adults living and working in the facility have a criminal record clearance. 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. The facility is two story family home with four bedrooms, two bathrooms, living room, kitchen and garage. LPAs and Licensee toured the home inside and outside. Licensee has a 3A40BC fire extinguisher, and a first aid kit is located in the pantry. Smoke alarm and carbon monoxide detectors were observed to be in operational order. Hazardous and personal hygiene items are inaccessible to children in care. Sharp utensils are stored on upper shelf in pantry. LPAs observed a fireplace that was appropriately barricaded. The outdoor play area is fenced and all toys are age appropriate. LPAs observed a a fountain in the backyard filled with rocks to ensure there is no standing water. Licensee stated there are weapons in the home and LPAs verified that weapons and ammunition were stored in separate locked safes. Licensee has a current Mandated Reporter Training Certificate that expires 11/1/2023. Licensee understands that this must be renewed every two years. A Current pediatric CPR and first aid training was verified and expires 12/2023. Report Continued on LIC809-C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: PENA, NORMA	FACILITY NUMBER: 393622766
	VISIT DATE: 06/22/2022

NARRATIVE

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Off limit areas are the entire second floor and the garage. Licensee acknowledged that children are never allowed in the off-limit areas. Off limit areas will remain inaccessible by gates, locked doors and supervision.

LPAs discussed safe sleep regulations and the requirement to check and log napping infants 24 months and under every 15 minutes. LPAs provided a copy of the Individual Sleeping Plan for infants under 12 months (LIC9227) and the Child Care Licensing Safe Sleep webpage as an additional resource: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep.

LPAs provided Licensee a copy of Forms/Records to Keep in Your Family Child Care Home (LIC311D) and discussed licensing requirements with Licensee including the posting of licensing inspection notices and reports, as well as injury and incident reporting. LPAs reminded Licensee that if any structural changes are made to the home, Licensing must be notified prior to construction. Finally, Licensee understands that licenses are not transferable, and once licensed, Licensee must live in the home and be present for 80% of the operating hours.

Licensee currently does not have any children enrolled that require Incidental Medical Services (IMS). LPAs discussed IMS services and the requirement to create a plan for providing IMS. Licensee acknowledges that if any IMS is provided in the future, a plan must be submitted to Licensing.

LPAs provided the contact information for the ADA: 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.

An exit interview was conducted, and the report was reviewed with the Licensee. Licensee was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

Report Continued on LIC809-C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: PENA, NORMA	FACILITY NUMBER: 393622766
	VISIT DATE: 06/22/2022

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Effective today 6/22/22, facility is approved for a Large Family Child Care License to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants. Without assistant, the ratios revert to those for Small Family Child Care home.

A notice of site visit was posted by LPA Mayberry and Licensee acknowledges it must remain posted for 30 days, and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

LIC809 (FAS) - (06/04)

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