394500489-9-27-2023-53-CC-DNGN-CW3RQC-20230927131319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 394500489
Report Date: 09/27/2023
Date Signed: 09/27/2023 01:13:30 PM

Document Has Been Signed on 09/27/2023 01:13 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	ACEVEDO, FLOR		FACILITY NUMBER:	394500489
ADMINISTRATOR:	ACEVEDO, FLOR		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 390-7858
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95219
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 4	DATE:	09/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Flor Acevedo		TIME COMPLETED:	01:30 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 September 27^th, 2023, at 9:00 AM, Licensing Program Analyst (LPA), David Nguyen met with Licensee, Flor Acevedo for the purpose of the unannounced annual inspection. The purpose of the unannounced annual inspection was explained. LPA was granted for entry into the facility by Licensee. There were four (4) children present at the time of inspection. Licensee's operating hours are Monday through Friday from 6:00 AM. to 6:00 PM. Meals—breakfast, AM snack, lunch, PM snack, and dinner—were provided to children in care. Purified water from water dispenser was provided for drinking water. LPA verified the annual license fees are current. 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. A health and safety inspection was conducted in all areas accessible to children. The detached single family one-story home has 3 bedrooms and 2 bathrooms. The off-limits areas in the home include all the bedrooms, attached two-car garage, laundry room, and dog’s area. Off-limits areas will remain inaccessible to children by closed locked doors, doorknob covers, and SUPERVISION. On-limits areas in the home include living room, dining area, kitchen, bathroom in the hallway, and backyard. LPA observed the required postings and a working phone. 3B40BC fire extinguisher meets regulations. LPA observed smoke and carbon monoxide detectors, and verified they were both functional. LPA toured the kitchen area and verified knives and cleaners were inaccessible to children in care. Licensee stated there are no weapons in the home. There are no bodies of water on the premises. LPA observed a restroom and verified that hazardous and toxic items were inaccessible to children in care. Licensee stated that her FCCH houses one (1) dog. Report continues on 809-C....(Page 2)

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ACEVEDO, FLOR	FACILITY NUMBER: 394500489
	VISIT DATE: 09/27/2023

NARRATIVE

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Children's files were reviewed. Emergency information and required immunization records were on file. LPA observed a current roster and documentation that a fire drill is conducted at least once every six months. The last fire drill was conducted and logged on 4/20/2023. Licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current in-person EMSA pediatric CPR and First Aid certification was verified and expires 10/22/2024. Licensee has a current Mandated Reporter Training Certificate that expires 9/27/2025. LPA discussed with Licensee the requirement of Pediatric CPR and First Aid, Child Care Provider Mandated Reporter Training, and Immunization Records for the provider assistant.

LPA did not observe the infants’ sleep logs during today's inspection. 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 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. LPA discussed the requirement to check and log infant napping every 15 minutes, for infants under 24 months. LPA provided Licensee a copy of LIC 9227—Individual Infant Sleeping Plan. LPA discussed the requirement to complete the Individual Infant Sleeping Plan for infants under twelve (12) months of age.

This provider is currently providing IMS services to children in care. Incidental Medical Services (IMS) policy was discussed. LPA observed one (1) medication (Epipen) without proper pharmacy labeling and its original box. LPA also observed no care plan for the enrolled child that required IMS. 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

Report continues on LIC809-C....(Page 3)

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ACEVEDO, FLOR	FACILITY NUMBER: 394500489
	VISIT DATE: 09/27/2023

NARRATIVE

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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/inspection-process

Exit interview conducted and report was reviewed with the licensee. A Notice of Site Visit was given and must remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for childcare updates, current forms, legislation, and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. Licensee's signature on this form acknowledges receipt of this form. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, LPA Nguyen informed licensee, Flor Acevedo that this report dated September 27th, 2023 documents one (1) Type B citation during today’s inspection.

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 09/27/2023 01:13 PM - It Cannot Be Edited

Created By: David Nguyen On 09/27/2023 at 12:19 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ACEVEDO, FLOR	FACILITY NUMBER: 394500489
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: 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 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	The licensee, Flor Acevedo agrees to comple the Infant Sleep Logs for infants under 24 months of age and checked on the infants every 15 minutes while they sleep or rest in her care. Licensee alsovagrees to subtmit the copies of the Infant Sleep Logs to LPA Nguyen by the due date of Plan of Correction (10/27/2023).

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Chayntel Hunter

LICENSING EVALUATOR NAME:

David Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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