<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408654
Report Date: 01/27/2023
Date Signed: 01/27/2023 11:33:12 AM

Document Has Been Signed on 01/27/2023 11:33 AM - 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:MORENO, KARENFACILITY NUMBER:
073408654
ADMINISTRATOR:MORENO, KARENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 533-4040
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:MORENO, KARENTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On January 27, 2023 at 08:45 AM, Licensing Program Analyst (LPA) Nyeesha Blount met with Licensee Moreno, Karen and assistant Rodriguezvilla, Patricia who is background cleared for an unannounced random annual inspection. There are (3) preschool children present during the time of the inspection. The facility’s operating hours are Monday -Friday 07:00 AM to 5:00 PM. LPA toured all on limits areas of the facility for health and safety inspection. All required postings are posted in the entry way of the home.

The home is a Three story home which consists of (2) living rooms, dining room, day care area, kitchen, (3) bedrooms, (2) bathrooms, and garage. The home is neat and clean and has central heating and ventilation for safety and comfort. There are sufficient age appropriate furnishings, toys, books and learning materials available. Licensee states that there are no weapons in the home. All hazardous materials and toxins are stored away inaccessible to children in care at the time of the inspection. The home is equipped with a 2A10BC fire extinguisher, working smoke detector, and working carbon monoxide detector. Pediatric CPR and First Aid are current and will expire on January 10, 2024.

ON LIMIT AREAS: (2) living rooms, kitchen, dining room, day care room, bathroom.

OFF LIMIT AREAS: will be the entire third level of the home. secured gates made inaccessible to the children in care.

OUTDOOR SPACE: The home does not have an outdoor play area, Licensee takes the children to the park across the street. There are no pools, hot tubs, or any other bodies of water on the premises during today's inspection.

ISOLATION AREA: will be in the living room on the second story.

SEE LIC809C FOR CONTINUANCE…….

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MORENO, KAREN
FACILITY NUMBER: 073408654
VISIT DATE: 01/27/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed the facility staff and children's records including parents' rights forms, emergency ID forms and consent for emergency medical treatment forms. Licensee CPR/First Aid, Mandated Reporter Certificate for Licensee is all up to date.

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.

Per 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.htmhttp://www.ada.gov/childqanda.htm
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC809 (FAS) - (06/04)
Page: 2 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MORENO, KAREN
FACILITY NUMBER: 073408654
VISIT DATE: 01/27/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.

Licensee was reminded about importance to stay in compliance with mandated reporter training and maintenance of sleep logs for all infants in care. In the areas that were evaluated, Mandated Reporter's Certificate was expired.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Exit interview conducted and report was reviewed with the licensee Moreno, Karen
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3