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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192002142
Report Date: 11/05/2021
Date Signed: 11/05/2021 04:47:26 PM

Document Has Been Signed on 11/05/2021 04:47 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CARDONA & RAYA FAMILY CHILD CAREFACILITY NUMBER:
192002142
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Rosa CardonaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Elka Chavez conducted an unannounced annual inspection in Spanish to the above facility on 11/05/2021. LPA arrived at the facility at 11:55 AM and met with Assistant, Jessy Raya who guided analyst on a tour of the facility. Licensee, Rosa Cardona arrived a 5 minutes after. Entrance Checklist for Family Child Care Homes was provided to the licensee upon entry. Per Licensee, there are 9 children that are currently enrolled. A current children’s roster was available for review. There were 4 children present upon arrival.

The home is a two story condominium. The condominium consists of 3 bedrooms, 1 and a half bathroom, living room, kitchen, dining room, attached garage, patio (fenced) and community pool. The following areas are used for day-care: living room, dining room area, bathroom (downstairs) and patio (fenced). Off limit areas include: All upstairs, kitchen, attached garage and community pool. LPA observed a safety gate at the bottom and top of the stairs. LPA observed the child safety gate at the bottom of the stairs was not closed upon arrival. LPA observed Licensee close the child safety gate at the bottom of the stairs and place a child safety gate at the top of the stairs. LPA observed a fireplace is barricaded by a book shelf and has a fireplace shield. Licenses states she does not use the fireplace. Kitchen is off-limits and has a safety gate to prevent access to children in care. The licensee understands that licensing staff may have access to off-limit areas during inspection visit if necessary. **Rooms that are off-limits need to be made inaccessible during operating hours**
Individuals who reside in the home were noted and discussed. Per Licensee, she currently has one assistant. All adults present in the home have obtained a criminal record clearance. Licensee states that there are no firearms stored in the home.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is telephone service via a landline and cell phone that is used. Safe toys play equipment and materials were observed
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Elka Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CARDONA & RAYA FAMILY CHILD CARE
FACILITY NUMBER: 192002142
VISIT DATE: 11/05/2021
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Detergents, cleaning compounds, medications, and other items which could pose a danger to children were
observed to be inaccessible to children. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock. The restroom that children use was observed to be safe and sanitary.

The valve on the required 2A10BC fire extinguisher indicates fully charged and was serviced on 12/20/21, as indicated on service tag. Smoke and carbon monoxide detectors were tested and are operable.

Licensee states that she is not currently caring for infants and there are no infants enrolled. Licensee states that if an infant is enrolled, the infant will sleep in the living room where they are constantly supervised. Appropriate sleeping arrangements and cots were observed. LPA did not observe cribs as there are no infants enrolled. Licensee advised cribs or play yards cannot hinder the entrance or exit from the sleeping space, mattresses shall be firm and covered with a fitted sheet that overlaps the underside, so it cannot be dislodged. Cribs and play yards must be free of loose articles and objects. No objects can be hung above or attached to the side of the crib. LPA advised the Licensee that infants cannot be swaddled, shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age.

Currently, children are using the patio (fenced) and community park for outdoor play time. The outdoor play area was observed to be fenced. There is a community pool that is 13 steps away from the licensee’s home. The gate to the swimming pool is locked with a key lock. Licensee has the key but stated that day-care children do not use the swimming pool.

The licensee completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 06/2023. LPA did not observe Pediatric First Aid and CPR for assistant. There are first aid supplies available. LPA advised that if a child shows signs of illness he/she/they shall be separated from other children.

Children’s records were reviewed, including emergency information and were observed to be incomplete. LPA did not observe children’s record for child #3.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Elka Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CARDONA & RAYA FAMILY CHILD CARE
FACILITY NUMBER: 192002142
VISIT DATE: 11/05/2021
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The licensee has proof of immunization against influenza, pertussis, and measles. LPA did not observe proof of TB for Licensee. LPA did not observe proof of MMR for Jessy Raya. LPA observed that the Licensee and assistant have a current Mandated Reporter AB 1207 Compliant Child Care Training Certificate on file.

All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Last drill documented was conducted on 4/09/21.

There is a cat and a dog (Labrador) on the premises. Licensee stated that the dog is kept upstairs in one of the off-limit bedrooms during hours of operation. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories are not permitted in a family child care facility. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

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.

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 [facility representative] 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.

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
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Elka Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CARDONA & RAYA FAMILY CHILD CARE
FACILITY NUMBER: 192002142
VISIT DATE: 11/05/2021
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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

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.


Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Rosa Cardona.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Elka Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2021 04:47 PM - It Cannot Be Edited


Created By: Elka Chavez On 11/05/2021 at 03:40 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CARDONA & RAYA FAMILY CHILD CARE
FACILITY NUMBER: 192002142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview and record review the licensee did not comply with the section cited above in 3 out of 4 children which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2021
Plan of Correction
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Licensee has enrolled assistant Jessy Raya in Pediatric CPR and First Aid training for 11/13/21.
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 observation,interview, record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2021
Plan of Correction
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Licensee stated that she will make sure that she will make sure immunizations are in the file and keeps record of them. LPA discussed and provided LIC 311D in Spanish to licensee for assistance.
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:Karen Chambers
LICENSING EVALUATOR NAME:Elka Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2021 04:47 PM - It Cannot Be Edited


Created By: Elka Chavez On 11/05/2021 at 03:40 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CARDONA & RAYA FAMILY CHILD CARE
FACILITY NUMBER: 192002142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021

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
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Based on observation,interview, record review, the licensee did not comply with the section cited above in 1 out of 4 child #3 was missing emergency information card from file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2021
Plan of Correction
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Licensee stated that she will have the child parent fill out the forms at pick up. Licensee stated that she will make sure this does not happen again. Licensee will make sure to have files completed prior to child starting day care.
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
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Based on observation and record review, the licensee did not comply with the section cited above in 9 out of 9 childrens address, physcian name and contact information was missing which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee stated that she will fill out the missing information tonight. Going forward she will make sure to fill out the form in it's entirety.
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:Karen Chambers
LICENSING EVALUATOR NAME:Elka Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2021 04:47 PM - It Cannot Be Edited


Created By: Elka Chavez On 11/05/2021 at 03:40 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CARDONA & RAYA FAMILY CHILD CARE
FACILITY NUMBER: 192002142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021

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 observation, and record review, the licensee did not comply with the section cited above in 4 out of 4 children in car which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2021
Plan of Correction
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LIcensee stated that she will have parent sign the form when parents pick children up. Licensee is going to make to have all parents sign the forms prior to attending day care.
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:Karen Chambers
LICENSING EVALUATOR NAME:Elka Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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