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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409133
Report Date: 04/25/2022
Date Signed: 04/25/2022 12:38:58 PM

Document Has Been Signed on 04/25/2022 12:38 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CABRERA BALMORI, SOFIAFACILITY NUMBER:
073409133
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:SOFIA CABRERA BALMORITIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Melissa Domantay and Nyeesha Blount conducted an unannounced random annual site inspection for this facility at 10:20AM. LPAs met with licensee, Sofia Cabrera Balmori, and toured all areas of the facility on limits for children in care for a health and safety inspection. Also present at the time of LPA's arrival were 4 children in care consisting of 1 infant and 3 preschoolers.

The On Limits areas of the home for children in care is the back family room. All other areas of home is off limits to children. Off limit areas are made inaccessible for children via child safety gating, closed doors and visual supervision. There are no hazardous items/toxins observed to be accessible to children. Furnishings and equipment, including infant sleeping equipment, are age appropriate and free of observed sharp/broken pieces. Per licensee there are no firearms stored or present on the premises. Isolation area will be in the back of day care area by the couch.
There is a working smoke detector, working carbon monoxide detector and fully charged fire extinguisher. The outdoor play area is fully fenced and available to children in care and is padded with turf to cushion a fall. There are no hazardous conditions observed in the outdoor play area. There are no pools, hot tubs or accessible bodies of water present. LPAs reviewed the facility's parent board located inside on the wall of the daycare area. Licensees CPR/First Aid is up to date, expires 10/2022 and mandated reporter training is up to date, expires 1/2023.

The attached Type A and Type B deficiencies are cited today and must be corrected by the due dates.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Melissa Domantay
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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 14
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: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133
VISIT DATE: 04/25/2022
NARRATIVE
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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.

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.

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.

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, no regulatory violations were observed.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Exit interview conducted and report was reviewed with the licensee Sofia Cabrera Balmori.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Melissa Domantay
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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2
3
4
Licensee shall have access to children's files at all times for LPA record review.
Type A
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above based on record review, due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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2
3
4
Licensee shall have access to children's files at all times for LPA record review.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(j)(2)(A)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Labored breathing.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
Type A
Section Cited
CCR
102425(j)(2)(B)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Signs of distress which includes but is not limited to flushed skin color, increase in body temperature and restlessness.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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2
3
4
Licensee shall have access to children's files at all times for LPA record review.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(j)(2)(C)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Infants up to 12 month of age who are sleeping in a position other than on their back.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no fire drills being conducted, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall set up fire drills every 6 months with local health department.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no fire drills being conducted, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall set up fire drills every 6 months with local health department.

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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 8 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
Type B
Section Cited
CCR
102418(g)(1)
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. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 9 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 10 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)(1)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). (1) The licensee shall keep the signed and dated notice form for at least three years following
termination of service to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 11 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(c)
Child's Records
(c) In any case in which the licensee cares for an additional child pursuant to Section 102416.5(b) for a Small Family Child Care Home or Section 102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child’s record, a copy of documentation verifying the child’s enrollment and attendance at kindergarten, including transitional kindergarten, or elementary school as required in Section 102416.5(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 12 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.

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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 13 of 14
Document Has Been Signed on 04/25/2022 12:38 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/25/2022 at 11:52 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to no access to children's files, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
1
2
3
4
Licensee shall have access to children's files at all times for LPA record review.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 14 of 14