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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153907149
Report Date: 09/02/2021
Date Signed: 09/03/2021 10:13:25 AM

Document Has Been Signed on 09/03/2021 10:13 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:PAZ, MARIA FAMILY CHILD CAREFACILITY NUMBER:
153907149
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Maria PazTIME COMPLETED:
02:00 PM
NARRATIVE
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On 9/2/2021, Licensing Program Analyst (LPA) Theresa Marquez conducted an unannounced annual inspection and met with Licensee, Maria Paz (Spanish/English Speaking). A tour of the home was conducted, and a census was taken. Current facility sketch reviewed, and Licensee confirmed the living room, dining/ kitchen area, bathroom near the laundry area and the fenced backyard are used for providing care and are accessible to day care children. All other rooms are off-limits and are made inaccessible by use of spinner knobs.

Medications and other hazardous items were inaccessible to children. LPA did not observe any poisons in the home. There was no fireplace. The fire extinguishers, smoke detectors, and carbon monoxide detector met Community Care Licensing (CCL) regulations. Heating/cooling and ventilation was sufficient for safety and comfort. There were no stairs in the home. Safe toys and play equipment were observed. Licensee had a working telephone and the above telephone number was verified. Adequate supervision was being provided during this inspection. Capacity as specified on the license was being maintained.

LPA discussed Safe Sleep Regulations with Licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping. There are no objects hanging above or attached to the crib or play yard. Infants in care are not swaddled. Licensee physically checks on sleeping infants every 15 minutes and documents any signs of distress, to include but is not limited to: flushed skin color, increase in body temperature, restlessness, and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.
The outdoor play area in the backyard is fenced. Licensee ensures that children in care are supervised at all times. There were no swimming pools, bodies of water, or firearms on the premises. LPA observed a properly anchored play climbing slide structure with gravel as padding. There are 2 dogs in the backyard. One large dog is inaccessible to children by a fenced dog run on the north side of the home. A small dog is accessible to children by roaming free in the backyard.
SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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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Document Has Been Signed on 09/03/2021 10:13 AM - It Cannot Be Edited


Created By: Theresa Marquez On 09/02/2021 at 12:10 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: PAZ, MARIA FAMILY CHILD CARE
FACILITY NUMBER: 153907149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2021
Section Cited
CCR
102418(a)

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IMMUNIZATIONS- 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.
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Licensee will obtain immunization records for Child #1 by 9/16/2021 and submit proof of records to the Community Care Licensing Palmdale
office.
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This requirement was not met as evidence by record review: Child #1 has no immunization records in facility file.
This poses a potential risk to the health, safety, or personal rights of children in care.
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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:Susie Fanning
LICENSING EVALUATOR NAME:Theresa Marquez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: PAZ, MARIA FAMILY CHILD CARE
FACILITY NUMBER: 153907149
VISIT DATE: 09/02/2021
NARRATIVE
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A sample of children’s records contained all emergency information specified by regulation. There were no excluded individuals present at this home. All adults who reside or work in the home had a criminal record clearance or exemption. A review of records indicated Licensee has proof of required immunization (Pertussis/Measles/Influenza) and/or written declaration declining flu shot. Licensee's Mandated Reporter Training was completed on 3/21/2021. Licensee's pediatric CPR and First Aid expires on 3/22/2022.

Incidental Medical Services (IMS) are not currently provided. Licensee is aware that an IMS plan is required to be submitted to the Licensing Office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA information line at (800) 514-0301 (voice), (800) 514-0383 (TDD), and website link: https://www.ada.gov/childqanda.htm. http://www.ada.gov/childqanda.htm

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms, and Regulations.

Business hours are Monday through Saturday 5:00 AM to 6:00 PM and other hours as arranged.

Per Title 22, Division 12, Chapter 3 of the California Code of Regulations, the following deficiencY wAS found: Immunization records for 1 of the 2 children present was not on file
(see LIC809-D):

An exit interview was conducted with Licensee. Licensee was provided a copy of the Facility Evaluation Report (LIC 809), Appeal Rights, and the Notice of Site Visit form (LIC 9213). The LIC 809 is required to remain in the facility for public review and the LIC 9213 is required to be posted for 30 days.
SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC809 (FAS) - (06/04)
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