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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415910
Report Date: 03/02/2022
Date Signed: 03/02/2022 05:19:44 PM

Document Has Been Signed on 03/02/2022 05:19 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CERVANTES, MARGARITAFACILITY NUMBER:
434415910
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Margarita CervantesTIME COMPLETED:
05:30 PM
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Licensing Program Analysts (LPAs) Deanna Villagrana and Teodoro Trujillo arrived to the home and met with license's 15 year old daughter. Daughter stated her mother was not present and she was taking care of children and that her brother Wuilmer Cervantes was present in the home. LPAs were granted entrance. Licensee arrived 5 minutes later with a school age child. LPAs explained the nature of today’s inspection to her. Present were licensee, licensee's adult son, 15 year old daughter and five day care children including two infants. Days and hours of operation are Monday to Friday, 6:00am to 6:00pm. The adults that reside in the home are licensee, her husband, two adult daughters, adult son, 15 year old daughter and 14 year old son.

A review of staff records on 02/28/2022 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Margarita Cervantes 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.


LPAs toured the indoor and outdoor areas of the home during today’s inspection. LPAs observed and infant in a car seat with a blanket placed over the car seat. Licensee's daughter stated the child was just waking up. Licensee stated child arrived at 8am. LPAs observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPAs did not observe stairs or a fireplace in the home. LPAs observed safe and sufficient materials, toys, and play equipment for the day care children. LPA's observed cleaning supplies under the bathroom sink, shampoos, conditioners and razors in the bathroom shower, and cleaning supplies under the kitchen sink accessible to children. LPAs observed a 2A10BC fire extinguisher that needs to be serviced. LPAs
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CERVANTES, MARGARITA
FACILITY NUMBER: 434415910
VISIT DATE: 03/02/2022
NARRATIVE
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observed a working smoke detector and a working carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: master bedroom/bath and two bedrooms. There are no bodies of water. Backyard is fenced. Off limits outdoor: entire backyard. Licensee uses the front yard for outdoor play and understands she must be present at all times as the front yard is not enclosed. Licensee states dog she has one dog that stays in the backyard and is vaccinated. LPA observed licensee has a current CPR and First Aid certification expiring 08/07/2023. Licensee's son did not have a current CPR/First Aid certificate and was left alone with children. Licensee showed LPAs she completed Mandated Reporter training but has not received her certificate.

LPAs did not observe a current roster of the children. LPAs did not observe a fire and disaster drill log. LPAs reviewed five children's files. Child 1 and 4 are missing LIC995. Child 1 is missing LIC9227. Child 1's immunization records must be updated. Licensee states day care is not insured. LPA discussed SB792 Immunization Requirements and observed licensee has immunization records on file.



Supervision of children was discussed with licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 8 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPAs observed licensee is not keeping a Safe Sleep Log for infants in care. LPA discussed the safe sleep regulations with licensee Margarita Cervantes 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 Margarita Cervantes 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.


LPAs discussed Zero Tolerance related regulations with licensee Margarita Cervantes and was advised of the assessment of $500 immediate civil penalty and an ongoing $100 per day per violation continues until the violation(s) is corrected. 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
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CERVANTES, MARGARITA
FACILITY NUMBER: 434415910
VISIT DATE: 03/02/2022
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/process.

Exit interview conducted and report was reviewed with the licensee Margarita Cervantes.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPAs Deanna Villagrana and Teodoro Trujillo informed licensee Margarita Cervantes that this report dated 03/02/2022 document(s) two Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPAs Deanna Villagrana informed the licensee Margarita Cervantes to provide a copy of this licensing report dated 03/02/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
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Document Has Been Signed on 03/02/2022 05:19 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 03/02/2022 at 04:25 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CERVANTES, MARGARITA
FACILITY NUMBER: 434415910

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022

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: (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
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Based on observation, the licensee did not comply with the section cited above. LPA's observed cleaning supplies under the bathroom sink, shampoos, conditioners and razors in the bathroom shower, and cleaning supplies under the kitchen sink accessible to children which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2022
Plan of Correction
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Licensee removed items during visit. Deficiency cited during visit.
Type A
Section Cited
CCR
102425(h)
Infant Safe Sleep
Car seats shall only be used for transportation purposes and shall not be used for sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed and infant in a car seat with a blanket placed over the car seatLicensee's daughter stated the child was just waking up which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2022
Plan of Correction
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Licensee's daughter removed the child from the car seat. Licensee understands infants may not sleep in car seats and should remove car seats from day care area.
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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


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Page: 5 of 11
Document Has Been Signed on 03/02/2022 05:19 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 03/02/2022 at 04:25 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CERVANTES, MARGARITA
FACILITY NUMBER: 434415910

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a 2A10BC fire extinguisher that needs to be serviced which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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Licensee must have fire extinguisher serviced or replaced and sent a photot to CCLD by POC date.
Type B
Section Cited
CCR
102417(g)(9)(A)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above. LPAs did not observe a fire and disaster drill log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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Licensee will submit a current fire and disaster drill to CCLD 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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


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Document Has Been Signed on 03/02/2022 05:19 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 03/02/2022 at 04:25 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CERVANTES, MARGARITA
FACILITY NUMBER: 434415910

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(g)
Infant Safe Sleep
An infant’s head shall not be covered while sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above. LPAs observed and infant in a car seat with a blanket placed over the car seat. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2022
Plan of Correction
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Licensee's daughter removed the blanket. Licensee understands infants should not be covered with blankets while sleeping.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Licensee's son did not have a current CPR/First Aid certificate and was left alone with children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2022
Plan of Correction
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4
Licensee stated she understands at least one adult in the home must have a current CPR/First Aid certificate when left with children.
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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 03/02/2022 05:19 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 03/02/2022 at 04:25 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CERVANTES, MARGARITA
FACILITY NUMBER: 434415910

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above. Child 1's immunization records must be updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee will submit a current immunization record for child 1 to CCLD by POC date.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above. Child 1 and 4 are missing LIC995. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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2
3
4
Licensee will submit LIC995 for child 1 and 4 to CCLD 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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 03/02/2022 05:19 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 03/02/2022 at 04:25 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CERVANTES, MARGARITA
FACILITY NUMBER: 434415910

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022

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. LPAs did not observe a current roster of the children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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2
3
4
Licensee will submit a current roster to CCLD by POC date.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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. Child 1 is missing LIC9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
1
2
3
4
Licensee will submit LIC9227 for child 1 to CCLD 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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


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