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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412698
Report Date: 03/25/2022
Date Signed: 03/25/2022 01:43:35 PM

Document Has Been Signed on 03/25/2022 01:43 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:GONZALEZ, JOSEFINAFACILITY NUMBER:
013412698
ADMINISTRATOR:JOSEFINA GONZALEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 732-6534
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 2DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Facility RepresentativeTIME COMPLETED:
01:41 PM
NARRATIVE
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On 3/25/2022 at 11:37am Licensing Program Analyst (LPA) Morgan Pringle met with facility representative Ana Morales for an Unannounced Annual Inspection. Present during the inspection were two (2) helpers, Ana Morales and Rosa Morales, and two (2) infants. Both helpers are fingerprint cleared and associated to the facility. Licensee was out attending to family matters. Licensee’s home was toured for a health and safety inspection. The facility operates 7:00am – 6:00pm, Monday - Friday.

ON LIMITS AREA: Kitchen, Living Room, Dining Area, Enclosed Patio/Childcare Room, Bedroom next to Childcare Room, Two (2) Bathrooms and Backyard


OFF LIMITS AREA: Three (3) Bedrooms along hallway and Garage
ISOLATION AREA: Living Room

The facility is a single-story home owned by the Licensee. The inside and outside of the home were observed to be neat, clean with ample age appropriate materials for the children. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there are no firearms and no pets in the home.

The home has one (1) fully charged 3A40BC fire extinguishers located in the childcare room next to the exit door on the left side of the room. One (1) working smoke detector and carbon monoxide detector is in the childcare room. There is one (1) fireplace in the living room that has a locking glass door making it inaccessible to the children in care. LPA did not observe any harmful bodies of water in or around the home.

Continued on LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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 03/25/2022 01:43 PM - It Cannot Be Edited


Created By: Morgan Pringle On 03/25/2022 at 01:11 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GONZALEZ, JOSEFINA
FACILITY NUMBER: 013412698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022

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
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Based on interview and file review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2022
Plan of Correction
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Licensee will conduct a fire/disaster drill and send proof of documented drill to LPA Pringle by POC date.
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
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Based on record review and interview the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
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Licensee will complete Mandated Reporter training or provide proof of valid certificate to LPA Pringle by POC date.
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:Jason Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GONZALEZ, JOSEFINA
FACILITY NUMBER: 013412698
VISIT DATE: 03/25/2022
NARRATIVE
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The Licensee’s Health and Safety training with the lead poisoning component has been completed. Pediatric CPR and First Aid training is complete and expires 3/2024. Licensee’s helper A. Morales that is present has a current Pediatric CPR & First Aid certificate that expires 3/2024. Licensee’s Mandated Reporter status is unknown. Licensee could not be reached during inspection. Last known training was taken 4/4/2018 (See LIC809-D). All required forms are posted and visible for public view in the childcare room. Fire/disaster drill log is not up to date. Last drill logged was 10/25/2019 (See LIC809-D). LPA obtained the children’s files, helpers A. Morales’ file, who is an employee, and facility roster. All files were complete. Helper did not have a file on record. LPA provided proper documentation to helper and provided technical assistance via email to Licensee (See LIC9102TV).

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.

Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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 LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GONZALEZ, JOSEFINA
FACILITY NUMBER: 013412698
VISIT DATE: 03/25/2022
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To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Licensee 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.

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


Exit interview conducted and report was reviewed with facility representative Ana Morales.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
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