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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515406344
Report Date: 05/13/2022
Date Signed: 05/13/2022 01:31:17 PM

Document Has Been Signed on 05/13/2022 01:31 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:AGUILAR, EVANGELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 632-0339
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
05/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Evangelina Aguilar TIME COMPLETED:
01:30 PM
NARRATIVE
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On 5/13/22 at 12:21 LPA Mendez conducted a case management. During the visit LPA Mendez observed a child sleeping in the swing and infants in care had no proof of documentation regarding infant safe sleep every 15 minute checks.
The following deficiencies were cited: infant was sleeping in a swing and no nap logs were on file. (see LIC 809D):
LPA Mendez informed licensee to provide a copy of this licensing report dated 05/13/2022 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. Exit interview conducted and report was reviewed with the facility representative
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Bianca Mendez
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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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Document Has Been Signed on 05/13/2022 01:31 PM - It Cannot Be Edited


Created By: Bianca Mendez On 05/13/2022 at 12:31 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: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2022
Section Cited
CCR
102425(i)(j)

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i) 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.

(j) The provider shall supervise infants while they are sleeping and adhere to the following requirements:


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Licensee will go through safe sleep regulations and will ensure that all infants are sleep in a crib or play yard. Licensee will submit in writing that she has read through safe sleep regulations and inform her assistants. Plan of correction is due 5/16/22.
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This requirement was not met as evidenced based on LPA Mendez's observation. LPA Mendez observed one infant in care sleeping in the swing. Licensee did not ensure infants were provided safe sleep equipment.by allowing them to sleep in swings.
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Type A
05/13/2022
Section Cited
CCR102425(j)(d)

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(j) The provider shall supervise infants while they are sleeping and adhere to the following requirements: Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:
a. Date.
b. Infant’s name.
c. Time of each 15-minute check.
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Licensee will start documenting for every infant every 15 minute check and have documentation available for licensing.
Plan of correction will be submitted by 5/16/22.
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This requirement was not met as evidenced based on LPA Mendez observation and review. Licensee does not have documentation for 3 infants in care regarding 15 minute check.
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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:Megan Aviles
LICENSING EVALUATOR NAME:Bianca Mendez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
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