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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409133
Report Date: 09/29/2023
Date Signed: 09/29/2023 03:54:39 PM

Document Has Been Signed on 09/29/2023 03:54 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: 9DATE:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sofia Cabrera BalmoriTIME COMPLETED:
04:06 PM
NARRATIVE
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On September 29, 2023 at 1:00pm Licensing Program Analyst (LPA) Indira Loza met with Licensee Sofia Cabrera Balmori for the purpose of conducting an unannounced 1-year annual inspection. Present during today's inspection were the Licensee, her mom/assistant, one school-age child, 7 preschool-age children, and one infant. Operating days and times are Monday - Friday 6am-6:00pm.

The home is a two story single family house; with three bedrooms, three bathrooms, living room, dining area, kitchen, backyard, large backroom (main daycare area), a garage converted to a bedroom, and a storage room in the backyard.

On Limit Areas - the large backroom next to the kitchen, which has a bathroom and small kitchen, and the backyard.
Off Limit Areas - Converted garage, all three bedrooms, main kitchen, and the bathroom in the main area of the home and the one in the upper level.
ISOLATION AREA - is on the couch in the main daycare area.

At 1:00pm LPA arrived and noticed 9 children in care at the same time. The home has a fully charged 3A40BC fire extinguisher, a working combined smoke/carbon monoxide detector in front of the door to the house, and a working telephone. Licensee does not have Liability Insurance and was reminded to have parents of newly enrolled children to sign the "Affidavit Regarding Liability Insurance for Family Childcare Home" (LIC 282). Per the Licensee there is nobody in the home with firearm. The Licensee has a current CPR/First Aid certificate which expires on January 1, 2024. The licensee and her assistant did not have a current Mandated Reporter certificate. The home has heating and ventilation for safety and comfort. LPA observed the backyard to be clean, Licensee has ample age-appropriate toys and learning materials in the home. Toxins, medicines, and hazardous items were inaccessible during today's inspection. The Licensee would provide breakfast, lunch, and two snacks.
**********************************Report Continues on LIC 809-C*******************************
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133
VISIT DATE: 09/29/2023
NARRATIVE
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The Licensee and her mother have a current CPR certificate which expires Januray 2025. LPA provided the Licensee with the Infant Safe Sleep Regulations and a copy of the "Individualized Safe Sleep Plan" (LIC 9227) was provided.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02. When any IMS is 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, 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 onFamily 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.

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

**********************************Report Continues on LIC809-C********************************

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
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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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133
VISIT DATE: 09/29/2023
NARRATIVE
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www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

During the Exit Interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



Exit interview conducted and report was reviewed with Licensee Sofia Cabreara Balmori
Report and Appeal Rights were provided.
A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2023 03:54 PM - It Cannot Be Edited


Created By: Indira Loza On 09/29/2023 at 03:05 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(c)
Staffing Ratio and Capacity
(c) The total licensed capacity for a Small Family Child Care Home shall not exceed eight 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 as there were 9 children in care during the first half hour of the visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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The Licensee shall ensure to always maintain the ratio at 8 children or less during operation hours, LPA will return to the faiclity to verify that the licensee if complying with the regulation.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2023 03:54 PM - It Cannot Be Edited


Created By: Indira Loza On 09/29/2023 at 03:05 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 interview and record review, the licensee did not comply with the section cited above in 2 out of 2 staff did not have a current Mandated reporter certificate which poses a potential health, safety or personal rights risk to persons in care. potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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The lIcensee and her mother must have the current Mandated Reporter certificates and email them to the LPA.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above in two out of two people did not have the immunization that prevents Pertussis and Measles which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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The Licensee shall provide proof of having the required immunizations by October 27, 2023.
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:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2023 03:54 PM - It Cannot Be Edited


Created By: Indira Loza On 09/29/2023 at 03:05 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023

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
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Based on record review, the licensee did not comply with the section cited above as the children did not have the affidavit in their file and the ones that were filled out, were in the incorrect space, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2023
Plan of Correction
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The Licensee shall have all the parents sign the Affidavit form and email them to LPA Loza.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in each child's file did not have an infant sleep log or Infant sleep plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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The Licensee review the CDSS Safe Sleep website and describe what they have learned about Infant Safe Sleep.
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:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023


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Document Has Been Signed on 09/29/2023 03:54 PM - It Cannot Be Edited


Created By: Indira Loza On 09/29/2023 at 03:24 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CABRERA BALMORI, SOFIA
FACILITY NUMBER: 073409133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8595
A licensed child care facility or home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as specified in paragraph (1) of subdivision (a) of Section 1596.893b.

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 in the Licensee did not have the children's parents sign the Acknowledgement of Receipt of Licensing Forms (LIC9224) which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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The Licensee shall email the LPA a copy of all signed Acknowledgement of Receipt of Licensing Forms (LIC9224) by October 27, 2023.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023


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