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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421600
Report Date: 02/07/2024
Date Signed: 02/07/2024 01:41:53 PM

Document Has Been Signed on 02/07/2024 01:41 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: 11CENSUS: 10DATE:
02/07/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Rosa HenriquezTIME COMPLETED:
01:40 PM
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On 2/7/2024 at 9:30am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Rosa Henriquez for a Required – 3 Year Inspection. Present during the inspection was the Licensee, her Helper Cessia Campos Shashte, six (6) preschool age children and four (4) infants. Licensee’s husband and their three adult children were present in the home in off-limit areas as well. Licensee lives in the home with her husband, Wilfredo Henriquez, and their three (3) adult children, Catherine Shashte, Justin Henriquez, and Jasmine Henriquez. The facility operates from 7:30am – 5:30pm, Monday – Friday.

ON LIMITS AREA: Living Room, Dining Area, Kitchen, Family Room (used as childcare play area), Downstairs Bathroom and Backyard
OFF LIMITS AREA: Entire 2nd Floor and Garage
ISOLATION AREA: Living Room

The facility is two story home owned by the Licensee. The inside of the home is observed to be neat, clean with ample age-appropriate materials for the children. All toxins and cleaning products were observed to be in inaccessible areas. At 9:15am LPA observed a large kitchen knife on the kitchen counter. LPA rechecked the area at 10:13am and the knife had not been moved (see LIC809D). Licensee stated she provides all food for the children which was observed to be properly maintained and stored. All food that may be brought from the children’s home will be properly labeled and stored. Licensee uses child sized table for eating that were observed to be clean and well maintained. LPA observed four (4) play yards used for sleeping that were observed to be well maintained. All off limit areas are made inaccessible with closed doors and locks. Licensee stated she will transport children from the nearby elementary school if needed. There is one (1) firearm and one (1) small dog in the home.


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SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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: 02/07/2024
NARRATIVE
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The home has one (1) fully charged 3A40BC fire extinguisher in the family room. There is one (1) working smoke detector in the family room and one (1) 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. When LPA arrived at the home, LPA observed that the staircase was not gated making it, and the off-limit second floor of the home, accessible to the children in care. LPA informed Licensee that the stairs must be gated at all times while children are in care (see LIC809D).

The backyard is fully fenced with ample materials for the children in care. Licensee uses the gate on the left side of the home as the childcare entrance and children are brought into the facility through the back sliding glass door. The gate has a latch on the outside to ensure extra safety when parents and/or adults leave the home. LPA reminded Licensee to always make sure the gate remains locked when children are in care. There were no harmful bodies of water in or around the home.

The facility is operating within its licensed capacity and is in ratio. Licensee’s Health and Safety training has been completed and EMSA approved Pediatric CPR & First Aid has been completed and expires 12/22/2024. Licensee’s Mandated Reporter has been completed and expires 10/25/2025. Fire/disaster drills have been conducted and recorded with the last drill logged 9/26/2023. All required forms are posted and visible for public view on the wall by the kitchen. Through record review and interview it was found that Licensee’s three (3) adult children living in the home have not obtained a criminal record, clearance, or exemption (see LIC809D). LPA asked Licensee is she was aware her children had not obtained a criminal record clearance and she stated, “yes.” Licensee stated she was aware that all three of her children needed a clearance or exemption while living in the home. LPA informed Licensee that all 3 of her adult children (ages 18,21 and 24) will need to submit a Request for LiveScan Service (LIC9163) no later than 2/8/2024. LPA obtained the children’s files, helpers files, and facility files. All files were complete.




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

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
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: 02/07/2024
NARRATIVE
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Deficiencies cited during LPAs inspection
· Licensee’s 3 adult children have not obtained a criminal record clearance, exemption or
· Large kitchen knife accessible to children
· Staircase not gated

LPA Pringle informed licensee Rosa Henriquez that this report dated 2/7/2024 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Pringle informed the licensee Rosa Henriquez to provide a copy of this licensing report dated 2/7/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.


Licensee was reminded that California law requires Licensees to report unusual incidents and/or injuries to children in care, to the child's parents, and to the Department within 24 hours by phone. Within seven (7) days from the incident, Licensee’s must submit the Unusual Incident/Injury form (LIC 624B) to the Department. Licensee was reminded that any structural changes or additions to the home must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drills must be conducted every six (6) months and documented. Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting https://mandatedreporterca.com/. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.




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

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: 02/07/2024
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, Licensee Rosa Henriqez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.


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

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 02/07/2024 01:41 PM - It Cannot Be Edited


Created By: Morgan Pringle On 02/07/2024 at 11:45 AM
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: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Licensee's 3 adult children, Catherine Shashte, Justin Henriquez and Jasmine Henriquez have not obtained a criminal record clearance before turning 18 years old or residing in the home. Licensee will ensure all 3 submit a completed Request for LiveScan Service (LIC9163) no later that the POC date. Licensee will send a copy of the completed Request form to LPA Pringle.
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: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


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: 02/07/2024
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

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

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















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

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 02/07/2024 01:41 PM - It Cannot Be Edited


Created By: Morgan Pringle On 02/07/2024 at 12:16 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: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(3)
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: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 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: 02/14/2024
Plan of Correction
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LPA observed the staircase in the home has not been gated. LPA Pringle verbally informed Licensee about the gate during the last inspection on 1/17/2023. Licensee will watch the "Locks and Inaccessibility Requirements in Child Care" video on the CCLD website and submit proof of gated staircase to LPA Pringle for 5 business days following todays inspection.
Type B
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 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: 02/09/2024
Plan of Correction
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LPA Pringle observed a large kitchen knife placed on the on-limit kitchen counter on 2 seperate occassions during the inspection. Licensee will watch the "Locks and Inaccessibility Requirements in Child Care" video on the CCLD website. Licensee will submit a statement to LPA Pringle describing how she will ensure harmful objects will remain inaccessable to the children moving forward.
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: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
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