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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515406344
Report Date: 05/14/2024
Date Signed: 05/14/2024 08:18:16 PM

Document Has Been Signed on 05/14/2024 08:18 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:AGUILAR, EVANGELINA FAMILY CHILD CARE HOMEFACILITY NUMBER:
515406344
ADMINISTRATOR/
DIRECTOR:		AGUILAR, EVANGELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 632-0339
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 14TOTAL ENROLLED CHILDREN: 16CENSUS: 11DATE:
05/14/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Evangelina AguilarTIME VISIT/
INSPECTION COMPLETED:
08:25 PM
NARRATIVE
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On 5/14/2024 at 1:35pm, an annual inspection was made to the facility by Licensing Program Analyst (LPA), Laura Chavez. Upon arrival to the home LPA observed two assistants supervising 11 children. Five children, three of which were infants were observed sleeping in strollers, two of the three infants in strollers had their strollers covered with blankets. The licensee arrived approximately 25 minutes later. The licensee was operating within the licensed capacity and ratio requirements.

The licensee offers care and supervision 7 days a week, 24 hours a day. The licensee understands that 24 hour care to one child at one time is not allowed. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the garage and second story of the home, and were made inaccessible by gates and locks. The children use the back yard as the outdoor play area and it is fully fenced. There is an in ground pool in the back yard. The pool is fully fenced with mesh pool fencing material. The fence meets pool fencing requirements.

Six children's records were reviewed at 2:09pm. There are currently 4 adults living in the home.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 16
Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 4 infants sleeping was covered with a blanket which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
1
2
3
4
The licensee agrees to provide a written statement that she and her assistants will review Title 22 Regulations and view the Departments website (https://ccld.childcarevideos.org) regarding Safe Sleep no later than end of the week. After reviewing the information on safe sleep the licensee agrees to provide a second written statement on how she and her assistants will ensure that the Safe Sleep requirements will be met. The initial written statement shall be submitted by 5/15/2024.
Type A
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 4 infants sleeping had blankets covering the strollers they were sleeping in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
1
2
3
4
The licensee agrees to provide a written statement that she and her assistants will review Title 22 Regulations and view the Departments website (https://ccld.childcarevideos.org) regarding Safe Sleep no later than end of the week. After reviewing the information on safe sleep the licensee agrees to provide a second written statement on how she and her assistants will ensure that the Safe Sleep requirements will be met. The initial written statement shall be submitted by 5/15/2024.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 16
Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(i)
Infant Safe Sleep
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 4 out of 6 infants observed sleeping had not been moved to a crib or play yard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
1
2
3
4
The licensee agrees to provide a written statement that she and her assistants will review Title 22 Regulations and view the Departments website (https://ccld.childcarevideos.org) regarding Safe Sleep no later than end of the week. After reviewing the information on safe sleep the licensee agrees to provide a second written statement on how she and her assistants will ensure that the Safe Sleep requirements will be met. The initial written statement shall be submitted by 5/15/2024.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 16
Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on an interview, the licensee did not comply with the section cited above. The licensee has not conducted a fire and disaster drill within the last 6 months which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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2
3
4
The licensee agrees to conduct a fire and disaster drill with children in care. The licensee agrees to continue to conduct drills as required. A copy of the documentation of the fire disaster drill shall be provided to CCLD on or before 6/14/2024.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 16
Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on an interview, the licensee did not comply with the section cited above in 4 out of 4 child where the licensee stated she and her assistants do not document the required 15 minute safe sleep which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to provide a written statement on how she will ensure the required documentation of infants sleeping will be met. Proof of correction shall be submitted to CCLD on or before 6/14/2024.
Type B
Section Cited
CCR
102425(j)(2)(A)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Labored breathing.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on an interview, the licensee did not comply with the section cited above in 4 out of 4 child where the licensee stated she and her assistants do not document labored breathing which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to provide a written statement on how she will ensure the required documentation of infants labored breathing if any will be met. Proof of correction shall be submitted to CCLD on or before 6/14/2024
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 5 of 16
Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on an interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to renew the Mandated Reporter Training as required and submit a copy of the certificate of completion on or by 6/14/2024.
Type B
Section Cited
HSC
1596.8662(c)
Administration of Child Day Care Licensing
(c) Current proof of completion for each licensed child day care provider or applicant for that license, administrator, and employee of a licensed child day care facility shall be submitted to the department upon inspection of the child day care or upon request by the department.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on an interview, the licensee did not comply with the section cited above in 3 out of 3 persons have not completed the Mandated Reporter Training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to ensure all employees, volunteers, etc. complete the Mandated Reporter Training as required and submit copies of their certificates of completion on or by 6/14/2024.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 6 of 16
Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on an interview the licensee did not comply with the section cited above in 3 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to provide a written statement on how she will ensure maintaining documentation of her personnel's immunizations as required. The written statement shall be submitted on or by 6/14/2024.
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
1
2
3
4
Based on an interview the licensee did not comply with the section cited above in 3 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to provide proof of current CPR/First Aid certification for Staff #1 and Staff #2. Copies shall be submitted to CCLD on or by 6/14/2024.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 7 of 16
Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(d)
Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on an interview, the licensee did not comply with the section cited above in 3 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to provide a written statement on how she will ensure to maintain personnel records and readily available for the licensing agency to review. The plan of correction shall be submitted to CCLD on or before 6/14/2024.
Type B
Section Cited
CCR
102416.2(a)(2)
Reporting Requirements
(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (2) Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on an interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to complete an updated Application for a Family Child Care Home License LIC279 showing all adults who have moved into the home.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 8 of 16
Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1
Admission Procedures and Authorized Representatives Rights
(9) Evidence of a current tuberculosis (TB) clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on an interview, the licensee did not comply with the section cited above in 3 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to provide TB clearances to CCLD for Staff #1, #2, and #3 on or before 6/14/2024.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on an interview, the licensee did not comply with the section cited above in 3 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to provide copies of Staff 1, 2, and 3 immunization records to show they have been immunized against Measles, Pertussis and Influenza. Copies of immunization records shall be submitted on or by 6/14/2024.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 9 of 16
Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 6 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to provide CCLD current immunization records for Child 1-6 on or by 6/14/2024.
Type B
Section Cited
CCR
102418(g)
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.

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 6 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to submit a written statement to CCLD on or before 6/14/2024 on how she will ensure documentation of each child's immunizations will be maintained.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 10 of 16
Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on record reviews, the licensee did not comply with the section cited above in 3 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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2
3
4
The licensee agrees to obtain completed LIC995A's for Child #3, #5, and #6. Copies shall be submitted to CCLD on or before 6/14/2024.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in 2 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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2
3
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The licensee agrees to obtain completed emergency cards for Child #5, and #6. Copies shall be submitted to CCLD on or before 6/14/2024.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


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Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record reviews, the licensee did not comply with the section cited above in 2 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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2
3
4
The licensee agrees to obtain completed the Affidavit Regarding Liability Insurance (LIC 282) for Child #5 and #6. Copies shall be submitted to CCLD on or by 6/14/2024.
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
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2
3
4
Based on record reviews, the licensee did not comply with the section cited above in 2 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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2
3
4
The licensee agrees to obtain completed Individual Sleep Plans for Infants #1 and #5. Copies shall be submitted to CCLD on or by 6/14/2024.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


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Page: 12 of 16
Document Has Been Signed on 05/14/2024 08:18 PM - It Cannot Be Edited


Created By: Laura Chavez On 05/14/2024 at 04:59 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
The licensee agrees to submit a written statement on how she will ensure children will not be made to or allowed to sleep in strollers. The plan of correction shall be submitted on or by 6/14/2024.
Type B
Section Cited
CCR
102417(g)(8)
(8) Each family chid 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 an interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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2
3
4
The licensee agrees to complete and submit a copy to CCLD of her Roster of Children in Care on or by 6/14/2024.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


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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: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344
VISIT DATE: 05/14/2024
NARRATIVE
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The following deficiencies were cited: CCR 102425(b), LPA observed a blanket covering the pac-n-play Infant #3 was sleeping in. 102425(g), LPA observed the pac-n-play Infant #3 was sleeping in covered with a blanket. LPA also observed strollers covered with blankets that Infants #4, and #6 were sleeping in. 102425(i), licensee failed to move sleeping Infants #1, #3, #5 and #6 to a crib or play yard. 102423(a)(2), LPA observed Child #2 & #3 sleeping in strollers. 102417(g)(8), the licensee did not have a Roster of Children in Care. 102417(m)(3), Affidavit Regarding Liability Insurance not available for Infants #5 and #6. 102425(c), Individual Sleep Plans not available for Infant #1 and #5. 102419(d), Notification of Parents Rights were not available for Infants #3, #5, and #6. 102417(g)(7), emergency information card not available for Infants #5 and #6. 102418(a)(g), documentation of immunization records not available for Infant #1, #3, #5, #6, and Child #2 and #4. 102416.1(d), Personnel records for Staff #1, #2, and #3 not available for review. 102416.2(a)(2). 102416.2(a)(2), licensee failed to notify the Department of adults moving into the home. 102416(c), current CPR/First Aid certification not available for Staff #1 and #2 who were observed alone with children in care. 102425(j)(2)(A), 15 minute sleep documentation is not being maintained for Infants #1, #3, #5, and #6. 102417(g)(9)(A), the licensee has not conducted a fire and disaster drill within the last six months. 102369(9), TB clearances not available for Staff #1, #2, and #3. HSC 1597.622(a)(1)(c), licensee did not maintain documentation of required immunizations for Staff #1,#2, and #3. 1596.8662(b)(1)(c), proof of Mandated Reporter Training not available for the licensee and Staff #1, #2, and #3. (see LIC 809D's):

LPA Laura Chavez informed licensee Evangelina Aguilar that this report dated 5/14/2024 documents three (3) Type A citation(s) which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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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: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344
VISIT DATE: 05/14/2024
NARRATIVE
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Also, LPA Laura Chavez informed the licensee to provide a copy of this licensing report dated 5/14/2024 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.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Licensee Evangelina Aguilar was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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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: AGUILAR, EVANGELINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515406344
VISIT DATE: 05/14/2024
NARRATIVE
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LPA discussed the safe sleep regulations with licensee Evangelina Aguilar 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee Evangelina Aguilar was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, Licensee Evangelina Aguilar, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

Exit interview conducted and report was reviewed with Licensee Evangelina Aguilar.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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