Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310443
Report Date: 03/16/2017
Date Signed: 03/16/2017 01:20:51 PM

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:SALCEDO, LORENAFACILITY NUMBER:
304310443
ADMINISTRATOR:SALCEDO, LORENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 773-4809
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:14CENSUS: 8DATE:
03/16/2017
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lorena SalcedoTIME COMPLETED:
01:30 PM
NARRATIVE
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An Annual inspection was conducted at the facility by LPA, Dean Valencia. A review of staff records 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 presently 4 adults living in the home.
During today’s visit the home and grounds were toured and the licensee was operating within the licensed capacity. During today's visit, there were 2 infants in care, and 6 preschool age children in care. Licensee had an adult assistant assisting with care of the children. Operating hours are 5am to 6pm, Mon–Fri. The floor plan was verified. Off limits areas are inaccessible by means of baby gates. The licensee's pediatric CPR/First Aid certification is current, which expires 4/2018. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Poisonous/Hazardous items are locked in the garage. There is a working smoke detector, carbon monoxide detector and fire extinguisher in the home. The licensee has a current roster of children in care and has conducted an emergency drill within the past six months. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's visit. The children use the backyard as the outdoor play area and it is completely fenced. There are no bodies of water on the premises. Children's records were reviewed and in substantial compliance. 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

continued on 809c.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2017
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SALCEDO, LORENA
FACILITY NUMBER: 304310443
VISIT DATE: 03/16/2017
NARRATIVE
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Proof of immunization against pertussis and measles for licensee/assistants/volunteers within compliance of SB 792, were unable to be provided during the visit. A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative. English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
Exit interview was conducted. Report reviewed and discussed. Notice of Site Visit was posted during the visit. 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. Appeal rights provided and explained. The director/licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. Licensee was informed of how/where to access regulations and forms from CCLD websites: www.ccld.ca.gov or Myccl.ca.gov. This report is to be on file and accessible for public review at the facility for at least 3 years.
The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2017
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SALCEDO, LORENA
FACILITY NUMBER: 304310443
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2017
Section Cited
HS 1597.622
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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.

The licensee and assistant did not have proof of immunizations against pertussis and measles avaialbel for review. This poses a potential threat to children's health and safety.
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Licensee stated she will submit hers and assistant's proof of immunization against pertussis and measles, by 4/6/2017.
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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) 703-2808
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2017
LIC809 (FAS) - (06/04)
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