Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501110
Report Date: 03/03/2017
Date Signed 03/03/2017 12:14:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:RIOS & GUTIERREZ FAMILY DAY CAREFACILITY NUMBER:
191501110
ADMINISTRATOR:RIOS,S & GUTIERREZ, EFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 593-0308
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:14CENSUS: 2DATE:
03/03/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Stella RiosTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
ANNUAL RANDOM INSPECTION CONDUCTED IN ENGLISH
An Annual Random Inspection was conducted by Cynthia Reyes LPA. Met with licensee, who guided the analyst on a tour of the facility on this date. This is a single home. Residing in facility are 4 Adults and 1 Child. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Day Care days and hours are: M-F 515 AM 715 PM

Areas used by children were inspected as follows: Kitchen, living room, dining room, 1 bath room, and back yard.

There are NO weapons, firearms, *swimming pool or spa on the premises. The backyard is adequately fenced. There are age appropriate toys and equipment on the premises. The smoke detectors, carbon monoxide and fire extinguisher (2A 10BC) are in operable condition. CPR/First Aid Exp. 01/25/2016.

Areas off limits include: Master bedroom w/bath, 2 other bedrooms, laundry area and front yard
**Rooms that are off-limits need to be made inaccessible during operating hours** .

Child Care Roster, Disaster Plan, Emergency Disaster Drill and Children's Records were reviewed.
Children records and required licensing forms were given & discussed as well as mandated child abuse reporting and criminal records clearance (finger prints and child abuse clearance) requirement.
-Web site address to order forms: http://www.dss.cahwnet.gov/cdssweb/On-lineFor_293.htm#l
-INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Cynthia ReyesTELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2017
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: RIOS & GUTIERREZ FAMILY DAY CARE
FACILITY NUMBER: 191501110
VISIT DATE: 03/03/2017
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The following was discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to licensure. Individuals within one month of their 18th birthday must be fingerprinted immediately. The existing, immediate $100 per individual Civil Penalty has been increased to an immediate $100 per day Civil Penalty, for a maximum of five days for the first violation and a maximum of 30 days for subsequent violations. If an individual has a clearance with the Department a criminal record clearance may be transferred. LIC 9182 Criminal Background Clearance Transfer Request may be used. No smoking, No infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category, earthquake – fire, disaster drills and safety, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal records, child abuse clearance and criminal records transfer requirements, SIDS, Never Shake A Baby flyers given and discussed, Incidental Medical Services (IMS) was discussed.

Licensee has been advised of the following:.
· Pools should be inaccessible by a pool cover or a 5-foot fence around the perimeter of the pool. If the fence is made out of chain link, the opening should not allow a golf ball to pass through. Fences made out of mesh will need to be approved by the department. Mesh fence will remain in place whenever licensed care is provided, and as long as the mesh fence makes the swimming pool inaccessible to children as determined by licensing staff- Licensee’s initials ( ).
· Pool cover label should read F1346-91 American Society for Testing Material and it should be able to withstand the weight of an adult without water above cover when standing.
· Dog(s) and or pets should be isolated from children in care.
· It is recommended that a First Aid kit be available on premises.
--100% Outdoor supervision is required at all times. If outdoor area not adequately fenced provider must be with children at all times when outdoors. Licensee's Initials( ).

The following deficiency's are cited in accordance with Title 22 of California Code of Regulations and discussed with licensee: See 809 D attached.

An exit interview conducted with licensee, appeal rights, progressive civil penalties were explained including a copy of this report was given to the licensee and LIC 9213—Notice of Site Visit was posted during this visit. Notice of Site Visit must be posted for 30 days. Failure to post required visit reports for 30 consecutive days will result in immediate civil penalty assessment of $100.

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
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Cynthia ReyesTELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2017
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: RIOS & GUTIERREZ FAMILY DAY CARE
FACILITY NUMBER: 191501110
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2017
Section Cited
102416(c)
1
2
3
4
5
6
7
Personnel Requirements

The licensee and other personnel as specified shall complete training pediatric cardiopulmonary resuscitation and pediatric first aid. The licensee was unable to provide proof at this time of current CPR/First Aid.
1
2
3
4
5
6
7
Licensee called and set up an apponment to replace her PED CPR & FIRST AID CARDS and submit by the POC date.
Type B
03/17/2017
Section Cited
102417 (g) (8)
1
2
3
4
5
6
7
OPERATION OF A FAMILY CHILD CARE HOME

All homes shall have a current roster of the children.

There is no completed roster of children.
1
2
3
4
5
6
7
Licensee states will submit A CURRENT UPDATED copy of the children's roster to the LPA by the POC date.
Type B
03/17/2017
Section Cited
102421(a)
1
2
3
4
5
6
7
Child Records.

Licensee shall maintain in each child's file all the required forms from the department. Children files are not complete.
1
2
3
4
5
6
7
Licensee states will completer each child file with the correct forms filled out and signed by parents, including immunization records by the POC date.
Type B
03/17/2017
Section Cited
102417(g9A1)
1
2
3
4
5
6
7
OPERATION OF A FAMILY CHILD HOME
All homes shall conduct fire and disaster drills at least once every three months, and document the date and time of each drill.
-Licensee has not documented a fire drill or earthquake drill.
1
2
3
4
5
6
7
Licensee agreed to document and run a fire/ earthquake drill by the POC due date and send a copy of the drill documented. .
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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Cynthia ReyesTELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2017
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: RIOS & GUTIERREZ FAMILY DAY CARE
FACILITY NUMBER: 191501110
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2017
Section Cited
102417(a)
1
2
3
4
5
6
7
Operation of a Family Child Care Home.

LPA observed several hazardous items in the back yard such as the rose bushes need to be barricaded, small tools need to be put away and cover properly placed on the BBQ which has a propane tank.
1
2
3
4
5
6
7
Licensee states will have all corrections done by the POC date and will submit proof.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Cynthia ReyesTELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2017
LIC809 (FAS) - (06/04)
Page: 4 of 4