426216545-3-3-2023-17-CC-MJIZ-CPKSSF-20230303130753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 426216545
Report Date: 03/03/2023
Date Signed: 03/03/2023 01:08:08 PM

Document Has Been Signed on 03/03/2023 01:08 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	HERNANDEZ LEYVA FCCH		FACILITY NUMBER:	426216545
ADMINISTRATOR:	EMMA HERNANDEZ LEYVA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(805) 332-7563
CITY:	GUADALUPE	STATE: CA	ZIP CODE:	93434
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	03/03/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Emma Hernandez Leyva		TIME COMPLETED:	01:15 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 March 3, 2023 @ 9:00 AM, Licensing Program Analyst (LPA) Martina Jimenez conducted an announced Inspection for the purpose of performing a pre-licensing inspection. LPA asked Applicant Pre- Screening questions related to COVID-19. Applicant's responses to the Pre-screening questions suggest no COVID-19 exposure on site. LPA Jimenez met with Emma Hernandez Leyva, Applicant and Juan Diaz De Dios, Assistant. The purpose of the Inspection was discussed. LPA Jimenez and Applicant together toured the interior and exterior of the home. The home is 3 bedrooms, 2 bathrooms single story home with an attached garage. All adults in the home are fingerprint cleared. During this tour the following was noted: Applicant applied for a Large Family Child Care license. Family members residing in the home are 2 adults. Per Applicant, the operating hours will be Monday through Saturday from 4:00 a.m. to 7:00 p.m. Applicant states she wants to care for children from birth to 12 years of age. All areas identified on the facility sketch were inspected. This is a single-story home which consists of three bedrooms, two restrooms, living room, kitchen, dining room, garage and completely fenced backyard. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. LPA observed backyard outdoor play area to be safe with age appropriate toys, games etc. The backyard is adequately fenced. There are no bodies of water observed. LPA observed a medium size German Shepherd, secured in the backyard. Continues on LIC 809C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: HERNANDEZ LEYVA FCCH	FACILITY NUMBER: 426216545
	VISIT DATE: 03/03/2023

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Off limit areas included: three (3) bedrooms, one (1) bathroom, and garage. LPA observed child safety a gate at the kitchen entrance, door covers on the bedroom doors and garage door making the areas, three bedrooms, one bathroom and garage inaccessible to children. LPA observed safety locks located in the kitchen and bathroom.

Areas used by children included: living room, hallway bathroom and backyard.

The applicant states that she will provide food for children in care. There are age appropriate toys and napping equipment on the premises. Knives are stored out children’s reach, inaccessible to children.

The required fire extinguisher 2A10BC was purchased in January 12, 2023. Smoke detector was tested at 10:14 AM and was functioning at the time of the visit. The carbon monoxide detector was tested at 10:14 AM and was functioning at the time of the visit. Per Applicant, there are no guns and ammunition in the home. First Aid and emergency kits are available.

The Applicant completed the Orientation on January 5, 2023. The Applicant has current Pediatric First Aid and CPR which expires, January 26, 2025. Applicant took the Preventative Health on January 19, 2023. Applicant completed the Mandated Reporter Training on January 30, 2023. Applicant and Assistant has proof of immunization per SB 792 against influenza, pertussis, and measles.

The following was discussed with the applicant:
· Individuals who are 18 years of age or older living in the home or working in the home, must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain the Criminal Record Background Check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.
· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification, TB clearance, immunization's, and a valid criminal record clearance associated to the facility license.
· A current roster of children enrolled must be available for review and maintained for a period of three years, even after children are no longer attending the facility.
· The fire extinguisher type 2A10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
· Changes in the home should be reported to the Department as soon as they occur such as construction,

CONTINUES ON LIC 809C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: HERNANDEZ LEYVA FCCH	FACILITY NUMBER: 426216545
	VISIT DATE: 03/03/2023

NARRATIVE

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remodeling, telephone number changes and/or if applicant moved to another location/ home.
Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Mandated reporter requirements were reviewed and explained.
· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a Family Child Care Home, 24/7.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

Incidental Medical Services (IMS) policy was discussed
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

· No prohibited equipment will be allowed or used in the home. No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

· All adults living and working in the home shall be made of aware of the Department inspection rights authority.

During this visit, the LPA reviewed Forms/Records to Keep in Your Family Child Care Home (LIC 311D) with the applicant. LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

LPA discussed with the applicant Safe Sleep Regulation, (PIN 20-24).

· Infant up to 12 months of age must be on their backs to sleep, unless there is a medical exemption from a licensed physician that allows for an alternative sleeping position.

CONTINUES ON LIC 809C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: HERNANDEZ LEYVA FCCH	FACILITY NUMBER: 426216545
	VISIT DATE: 03/03/2023

NARRATIVE

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· Cribs must be free from all loose articles and objects, including blankets and pillows.
· Mattress must be firm and include a tight-fitted sheet.
· infants must not be forced to sleep, stay awake, or stay in the sleeping area.
· Infants must not be swaddled while in care.
· An infant's head must not be covered while sleeping.
· If an infant falls asleep before being placed in a crib, for example, in a provider's arms or stroller, the provider must move the infant to a crib (or play yard for FCCHs) as soon as possible.
· Car seats will only be used for transportation and must not be used for sleeping within a childcare facility.
· All pacifiers cannot have anything attached, such as a stuffed animal or a clip meant to attach the pacifier to the infant's clothing.
· Providers must check on sleeping infants every 15 minutes and document their condition to check for signs of distress, which includes, but is not limited to labored breathing, flushed skin color, increase in body temperature, and restlessness.
· Each infant, up to 12 months of age, must have an Individual Infant Sleeping Plan (LIC 9227) on file, which will document the infant's sleeping habits, usual sleep environment, and the infant's rolling abilities.

LPA also advised against sleeping infants in a separate room.

Forms to be posted

LIC6101A Emergency Disaster Plan,
PUB394 Notification of Parents Rights Poster,
Facility License

Facility Records: LIC 624B Unusual Incident/Injury Report, LIC 9040 Child Care Facility Roster, LIC 9052 Employee Rights, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse,

Continues on LIC 809C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: HERNANDEZ LEYVA FCCH	FACILITY NUMBER: 426216545
	VISIT DATE: 03/03/2023

NARRATIVE

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Staff Forms/Records - any assistant present must have the following on file: Proof of TB clearance (within one year), Notice of Employee Rights (LIC 9052), Criminal Record Statement (LIC 508), Statement Acknowledging Requirements to Report Suspected Child Abuse (LIC 9180).

Children’s records requirements: LIC 700 Identification and Emergency Information, LIC 627 Consent for Emergency Medical Treatment, LIC 282 Affidavit Regarding Liability Insurance, LIC 9150 Parent Notification Additional Children in Care, Immunization record, PUB 72- Family Child Care Consumer Guide, LIC 995A Notification of Parent’s Rights

Applicant was made aware the responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.

The home will be Licensed once Applicant submits verification of the following:

1. Repair gate on the left side of the home

License is pending the above corrections.

Email verification of correction to: Martina.Jimenez@dss.ca.gov

Exit interview was conducted with Emma Hernandez Leyva, Applicant. The inspection visit was conducted in Spanish and report was translated in Spanish by LPA Jimenez. There were no deficiencies cites at this time. LPA observed licensee post the Notice of Site visit FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY. THIS REPORT MUST BE FILED IN FACILITY FILE AND MADE AVAILABLE FOR PUBLIC REVIEW FOR 3 YEARS.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC809 (FAS) - (06/04)

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