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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421600
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:06:40 PM

Document Has Been Signed on 01/17/2023 03:06 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:HENRIQUEZ, ROSAFACILITY NUMBER:
013421600
ADMINISTRATOR:HENRIQUEZ, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 244-7813
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Rosa HenriquezTIME COMPLETED:
03:05 PM
NARRATIVE
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On 1/17/2023 at 12:15pm Licensing Program Analyst (LPA) Morgan Pringle met with Rosa Henriquez for an Unannounced Annual Inspection. Present during the inspection was the Licensee, her helper, Maria “Sophia” Salgado Gomez, three (3) infants and eight (8) preschool age children. One (1) school age child arrived around 2:00pm. Licensee lives in the home with her fingerprint cleared husband W. Henriquez and their adult daughter M. “Catherine” Shashte Monroy. Licensee home was toured for a health and safety inspection. The facility operates 7:30am – 5:30pm, Monday - Friday.

ON LIMITS AREA: Living Room, Dining Area, Kitchen, Family Room, Downstairs Bathroom and Backyard


OFF LIMITS AREA: Entire 2nd Floor and Garage
ISOLATION AREA: Living Room

The facility is a two-story home owned by the Licensee. The inside of the home was observed to be neat, clean with ample age appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee provides all food for the children that is properly stored and maintained. All food that may be brought from the children’s home will be properly labeled and stored. Licensee stated there is one (1) firearm and one (1) dog in the home.


Continued on LIC809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: HENRIQUEZ, ROSA
FACILITY NUMBER: 013421600
VISIT DATE: 01/17/2023
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The home has one (1) 3A40BC fire extinguisher in the family room that is not fully pressurized. Licensee stated the extinguisher is one (1) year old and was given to her by a fire inspector. LPA instructed Licensee to purchase a new extinguisher in the meantime for safety. There is one (1) working smoke detector in the family room. There is one carbon monoxide detector at the top of the staircase. The home is equipped with central heat and air for proper ventilation. The fireplace in the family room is blocked by furniture making it inaccessible to the children in care. The stairs are gated and made inaccessible to the children in care. The backyard is fully fenced, clean, with ample age appropriate materials for the children. The right side of the backyard is used for storage and other outside plants. The right side of the backyard is gated making those materials and plants inaccessible to the children in care.

Licensee is operating within their licensed capacity and is in ratio. The Licensee’s Health and Safety training has been completed and CPR and First Aid training is complete with an expiration date of 12/22/2024. Licensee’s Mandated Reporter training is complete and expires 6/23/2023. LPA obtained the fire/disaster drill log. Log is complete with the last drill logged 12/20/2022. All required forms are posted and visible for public view next to the kitchen. Licensee stated that she does transport children. LPA obtained vehicle documentation and observed proper car seats for transportation. LPA obtained a sample of the children’s files, the assistant’s file and the facility roster. During LPA’s record review it was found that two (2) children were missing immunization records (See LIC809D).

Deficiencies Cited During Inspection


· Two (2) children in care missing immunization records

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.

Continued on LIC809-C

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

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
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: HENRIQUEZ, ROSA
FACILITY NUMBER: 013421600
VISIT DATE: 01/17/2023
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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.

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.

Continued on LIC809-C

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

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
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: HENRIQUEZ, ROSA
FACILITY NUMBER: 013421600
VISIT DATE: 01/17/2023
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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.

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


Exit interview conducted and report was reviewed with Licensee Rosa Henriquez.

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

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2023 03:06 PM - It Cannot Be Edited


Created By: Morgan Pringle On 01/17/2023 at 02:03 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: HENRIQUEZ, ROSA
FACILITY NUMBER: 013421600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record 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: 01/20/2023
Plan of Correction
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Licensee will obtain immunization records for both children. Licensee will send LPA Pringle proof of correction by 1/20/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jason Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


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