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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414063
Report Date: 09/01/2021
Date Signed: 09/01/2021 01:58:13 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/01/2021 01:58 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:ROJO, MAYRA GUADALUPEFACILITY NUMBER:
434414063
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Mayra Guadalupe RojoTIME COMPLETED:
01:45 PM
NARRATIVE
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On 9/1/2021 at 11:38am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Mayra Guadalupe Rojo for an Unannounced Annual Inspection. Present during the inspection was the Licensee, her fingerprint cleared helper, three (3) infants and four (4) preschool children. Licensee lives in the home with her fingerprint cleared husband and son, and her school age son. Licensee’s home was toured for a health and safety inspection. The facility operates from 7:30am – 5:30pm Monday – Friday.

ON LIMITS AREA: Kitchen/Dining Area, Bathroom 2, Playroom and Backyard


OFF LIMITS AREA: Office/Bedroom, Bedroom 2 and Garage
ISOLATION AREA: Dining Area

The facility is a single-story home rented by the Licensee. The inside and outside of the home were observed to be neat and clean with ample age appropriate materials for the children that are safe. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there no firearms and two (2) dogs. At 11:45am LPA observed that the licensee is out of ratio today. LPA informed Licensee that she is out of ratio and of the ratio regulations for a small family childcare home. LPA informed Licensee of the process of applying for a capacity increase, if desired.

The home has one (1) fully charged 3A40BC fire extinguisher in the kitchen next to the refrigerator. There is one (1) working smoke detector in both bedrooms, the dining area and the playroom. There is a working carbon monoxide detector in the kitchen and playroom as well. There is a heater along the bottom of the wall in the kitchen that does not get hot to the touch and is no danger to the children in care. The home is equipped with many windows and fans for proper ventilation as well.

Continued on 809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ROJO, MAYRA GUADALUPE
FACILITY NUMBER: 434414063
VISIT DATE: 09/01/2021
NARRATIVE
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The Licensee’s Health and Safety training has been completed CPR and First Aid training is complete an expires on 12/17/2021. Licensee’s Mandated Reporter training will be completed. Licensee state that she has been waiting for it to be available in Spanish. LPA informed her that it is now available. All required forms are posted and visible for public view in the playroom. LPA obtained the children’s files and the files for two (2) employees and the facility roster. All files were complete. LPA obtained the fire drill log which was completed. Last drill was logged on 8/20/2021.

Licensee was reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed. This facility provides IMS to children in care. Facility is following IMS plan on file. When any changes to the IMS plan is made, an updated 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.

Licensee is reminded that ALL employees, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3,000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter.

Continued on 809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ROJO, MAYRA GUADALUPE
FACILITY NUMBER: 434414063
VISIT DATE: 09/01/2021
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All fire/disaster drill must be conducted every six months and documented. The Licensee is reminded that any structural changes to the facility or additions to the childcare facility must be reported to Community Care Licensing.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates.

This report was read and given to the Licensee for a signature. There is one (1) deficiency being cited during this inspection. Exit interview conducted. Notice of Site Visit was given and must be posted for 30 days.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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Document Has Been Signed on 09/01/2021 01:58 PM - It Cannot Be Edited


Created By: Morgan Pringle On 09/01/2021 at 01:09 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: ROJO, MAYRA GUADALUPE
FACILITY NUMBER: 434414063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited
CCR
102416.5(a)

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102416.5(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement was not met as evidenced by: The Licensee was out of ratio. This poses a potential risk to the health and safety to children in care.
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Licensee will inform LPA of ratio for two (2) days. Upon completeion of report, deficiency will be cleared.

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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 Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


LIC809 (FAS) - (06/04)
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