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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153911338
Report Date: 11/15/2021
Date Signed: 11/15/2021 12:43:23 PM

Document Has Been Signed on 11/15/2021 12:43 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:RIVERA, MONIQUE FAMILY CHILD CAREFACILITY NUMBER:
153911338
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
11/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee, Monique RiveraTIME COMPLETED:
01:00 PM
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On 11/15/21, Licensing Program Analyst (LPA), Jose Penate conducted an unannounced Annual Required Inspection and was met by Licensee, Monique Rivera. Days and hours of operation are Monday – Friday 8:00AM - 5:00PM and/or arranged.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed, and Licensee confirmed that the areas of the home that day-care children will have access to are the entire lower floor minus the downstairs bedroom and garage. This is a two-story home with child safety gate located at the bottom of the stairs making the second floor off-limits to day-care children. All other rooms are off-limits and made inaccessible child safety locks. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition at this home. All poisons are kept in a locked storage area. No poisons were observed during the inspection.

There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. The home has working telephone service and LPA confirmed the phone number is (661) 472-7370.

There are no infants in care, LPA advised licensee that cribs and play yards are to be kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed by licensee, while asleep in the living 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.

Continued on LIC 809-C

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: RIVERA, MONIQUE FAMILY CHILD CARE
FACILITY NUMBER: 153911338
VISIT DATE: 11/15/2021
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Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Capacity as specified on the license is being maintained.

Licensee has a current roster of the children. An emergency fire/disaster drill has been completed and documented within the last 6 months. Licensee’s pediatric CPR/First Aid is current and will expire 8/2022. Mandated Reporter has been completed and will expire 9/2022. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being 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.



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.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

This report shall be made available to the public upon request.

LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
LIC809 (FAS) - (06/04)
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