Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310430
Report Date: 10/19/2016
Date Signed: 10/19/2016 10:40:38 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MARTIR, CELIAFACILITY NUMBER:
304310430
ADMINISTRATOR:MARTIR, CELIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 726-4272
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:14CENSUS: 3DATE:
10/19/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Celia MartirTIME COMPLETED:
11:00 AM
NARRATIVE
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(2) An unannounced Random/Annual visit was conducted today by Licensing Program Analyst (LPA), Jacqueline Moore, who met with licensee, Celia Martir. LPA was allowed entrance into the facility by licensee. The census included 3 preschoolers whom were in the living room and in the day care play room with the licensee and assistant upon LPA' s arrival. Licensee stated that 1 of the day care children was licensee's niece. Also present and assisting with the day care was adult assistant Aimee Vo. A review of criminal record clearances 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 2 adults and 2 minors living in the facility.

Licensee stated that OFF LIMITS areas include: kitchen, bedrooms, bathroom inside of bedroom, and detached garage. Licensee acknowledged that children may never enter these off-limit areas. The day-care area was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medication, and hazardous items that can pose a danger to children. Per licensee there are no weapons or firearms in the facility. No bodies of water were observed. Fireplace was screened. There are age appropriate toys and equipment for ages served. Fire/disaster drill log was reviewed. Copy of the children's roster was given to LPA during visit.
Outdoor play area is the back yard which was fenced, there are safe and age appropriate toys for children to use. The required fire extinguisher (2A10BC), smoke detector, and carbon monoxide detector were in operable condition. Children's and staff's files were reviewed. Licensee had current CPR/First Aid cards which will expire (08/28/18).
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. (Con't on LIC 809 C)
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2016
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MARTIR, CELIA
FACILITY NUMBER: 304310430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2016
Section Cited
H&S1597.622(c)
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Employees or volunteers at family day care home; immunization requirements; records; exemptions The family day care home shall maintain documentation of the required immunization's 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.
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Licensee stated both the licensee and assistant have had the required immunization's. Licensee will send a copy of the immunization's to LPA Moore by due date of 11/21/16 via email Jacqueline.moore@dss.ca.gov.
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Licensee and assistant did not have documentation of Influenza, Pertussis and Measles immunization's on file for review during today's visit. This may be a potential health and safety risk to children in care.
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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: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2016
LIC809 (FAS) - (06/04)
Page: 3 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MARTIR, CELIA
FACILITY NUMBER: 304310430
VISIT DATE: 10/19/2016
NARRATIVE
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Licensee and assistant did not have the required immunization's on file for Influenza, Pertussis, and Measles. Licensee stated both the licensee and assistant have had the required immunization's, however both licensee and assistant did not have the immunization's on file during today's visit.
A tour of the facility which included the living room, napping room, day care playroom, hallway bathroom and back yard was conducted during visit and there were deficiencies cited today.
The facility was found to be out of compliance with Title 22 regulations. The deficiencies were reviewed, discussed and cited on the LIC 809 D.

The following were discussed: Individuals who are 18 years of age or older living in the home must be fingerprinted cleared prior to presence in the facility. Live Scan tel# (800)315-4507, complete LIC9163. Criminal record clearances/exemption transfer requests (contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182) with copy of ID and (LIC 508) to fax# (714)703-2831 prior to hiring staff.


LPA reviewed Unusual Incident Report form, advised to contact Licensing Officer of the Day within 24 hours and complete the Unusual Incident Report (LIC 624) within 7 days.
LPA reminded licensee of requirements of disaster drills, posting requirements, children records, mandated child abuse and injury/death reporting, SIDS, Never Shake a Baby, Centralized Complaint and Information Bureau (Copy was given), CA Child Passenger Safety Law (copy was given), Quarterly Updates, and SB 792 (copy was given).The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf
An exit Interview was conducted. Report was reviewed and discussed.

The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. LPA informed the licensee of how to access regulations and forms from CCLD websites: www.ccld.ca.gov or Myccl.ca.gov and/ or http://ccld.ca.gov/PG411.htm. This report is to be on file and accessible for public review at the facility for at least 3 years.

SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2016
LIC809 (FAS) - (06/04)
Page: 2 of 3