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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475407549
Report Date: 07/16/2021
Date Signed: 07/16/2021 12:02:32 PM

Document Has Been Signed on 07/16/2021 12:02 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:BAEZ, ANNA FAMILY CHILD CARE HOMEFACILITY NUMBER:
475407549
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Anna BaezTIME COMPLETED:
12:15 PM
NARRATIVE
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On 7/16/21 at 10:15am inspection was made to the facility by Licensing Program Analyst (LPA), Snow A review of staff records on 6/18/21 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently 2 adults living in the home.

At 10:30 am the home was toured inside and outside. The licensee and was supervising 6 children, and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 7:15a-5p Monday–Friday. The floor plan submitted by the licensee was reviewed and verified.
The following areas are off limits to children: The back yard, trampoline and the laundry room and inaccessible with a gate and the the adult bedroom is locked. The detached garage contains poisons and is key locked,

Poisons are locked in the detached garage. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) are stored out of the reach of children. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: BAEZ, ANNA FAMILY CHILD CARE HOME
FACILITY NUMBER: 475407549
VISIT DATE: 07/16/2021
NARRATIVE
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 The home is clean, orderly and comfortable. There are safe toys and equipment available for children. There is a working telephone in the home.
There are cribs/play yards available for napping infants. Cribs have firm mattresses and are free of loose objects. Bedding is laundered weekly, and soiled bedding is stored inaccessible to infants. Napping infants shall be checked on every 15 minutes, and checks shall be documented. No infants were observed to be swaddled, and infants under 12 months are placed on their backs for sleeping. The licensee did not have sleep records or a sleep plan for infant #1.

The children use the front yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard. 4 children's records were reviewed at 11am; required emergency information forms were observed to be on file. Individual Sleeping Plan were on file for infants under 12 months of age. The licensee and all employees have the required immunizations on file. The licensee has current pediatric CPR and First Aid certification, which expire on 5/15/23.

This report was reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2021 12:02 PM - It Cannot Be Edited


Created By: Jaime Snow On 07/16/2021 at 11:26 AM
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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: BAEZ, ANNA FAMILY CHILD CARE HOME
FACILITY NUMBER: 475407549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2021
Section Cited
CCR
102435(c)&(d)

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Infant Sleep Plan: An Individual Infant Sleeping Plan LIC 9227 shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file AND The provider
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The licensee agrees send a statement stating that she reviewed the infant sleep Regulations & Guidelines & PowerPoint provided by the LPA. The licensee agrees to provide a completed copy of
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shall supervise infants while they are sleeping and physically check on the infant every 15 minutes. The regulation was not met as evidenced by no sleep records or sleep plan for Infant #1.
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 Infant #1 Individual Infant Sleeping Plan (LIC9227) & to provide a copy of the 15 minutes checks documentation to CCLD on or before 7/19/21.

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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:Erin Virrueta
LICENSING EVALUATOR NAME:Jaime Snow
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021


LIC809 (FAS) - (06/04)
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