197415541-9-12-2024-12-CC-MRIA-D92RGH-20240912130046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197415541
Report Date: 09/12/2024
Date Signed: 09/12/2024 01:01:14 PM

Document Has Been Signed on 09/12/2024 01:01 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	RIVAS FAMILY CHILD CARE		FACILITY NUMBER:	197415541
ADMINISTRATOR/ DIRECTOR:	RIVAS, ROSA M.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 408-0416
CITY:	SAN FERNANDO	STATE: CA	ZIP CODE:	91340
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 3	DATE:	09/12/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Rosa Rivas, Licensee		TIME VISIT/ INSPECTION COMPLETED:	01:05 PM

NARRATIVE

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On Thursday, September 12, 2024, at 9:35 a.m., Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with licensee Rosa Rivas who granted access and guided LPA Rivera on a tour of the facility.

Family members residing in the home have been discussed with licensee and are cleared. LPA observed 1 infant and 2 preschool children present. LPA observed facility to be within ratio. Operating hours are Monday to Saturday from 6:00 a.m. to 6:00 p.m. and care for children ages 0 to 11 years old. Annual fee is current.

This facility is a one-story home that consists of 4 bedrooms, 2 bathrooms, kitchen, living room, family room (daycare) and front and backyard fenced.

Areas off limits to children include- All bedrooms, master bathroom and backyard.

Areas accessible to children include- family room (daycare), bathroom located in the hallway, kitchen, and front yard.

At approximately 10:00 a.m., LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone and landline). For ventilation, LPA Rivera observed central AC/heater and the vents located on the ceiling and a mini split AC. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA did not observe a fireplace nor a wall heater. LPA observed 4 play pens and observed to be free from bumper pads, blankets, pillows and hanging items.

LPA Rivera observed cleaning compounds items, stored underneath the kitchen sink, and observed a childproof lock in place, making it inaccessible for children to open. LPA observed the knives and sharp objects stored on top behind the kitchen sink faucet making it inaccessible for children to reach. For water drinking, licensee stated she provides filtered water. The licensee stated the facility provides meals and snacks. LPA informed licensee any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. Licensee stated she currently does not have any

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 09/12/2024 01:01 PM - It Cannot Be Edited

Created By: Mayra Rivera On 09/12/2024 at 11:07 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: RIVAS FAMILY CHILD CARE	FACILITY NUMBER: 197415541
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 interview and record review, the licensee did not comply with the section cited above in not completing the safe sleep log daily for child #1. Licensee stated forgets to document and last date recorded on log is 7/31/24 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2024
	Plan of Correction
1 2 3 4	Licensee stated understood the importance of completing the sleep logs and will resume daily when child or children under are present. Will submit proof of correction by due date.

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not obtaining a copy of the assistant immunization record (TDAP, MMR, Influenza or influenza declination) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2024
	Plan of Correction
1 2 3 4	Licensee stated, assistant will go to the clinic to request copy of immunization record and request TDAP vaccine and blood work for MMR. Licensee stated will submit proof by due date.

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:

Lady King

LICENSING EVALUATOR NAME:

Mayra Rivera

LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 11

Document Has Been Signed on 09/12/2024 01:01 PM - It Cannot Be Edited

Created By: Mayra Rivera On 09/12/2024 at 11:07 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: RIVAS FAMILY CHILD CARE	FACILITY NUMBER: 197415541
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 in not having child #2 child's record which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2024
	Plan of Correction
1 2 3 4	Licensee called parent to remind to bring LIC 700, LIC 282, LIC 627, LIC 995A, and immunizations. Licensee stated will inform parent child cannot return to care if documents are not received. Licensee stated will submit proof by due date.

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:

Lady King

LICENSING EVALUATOR NAME:

Mayra Rivera

LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: RIVAS FAMILY CHILD CARE	FACILITY NUMBER: 197415541
	VISIT DATE: 09/12/2024

NARRATIVE

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children with severe food allergies nor on medication.

At approximately 10:10 a.m., LPA Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA observed the bottom sink cabinet closed and did not observe hazard materials and observed the bathroom to be in good condition. LPA reminded licensee any personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Rivera asked the licensee if there were any pets, poisons, firearms, weapons, or bodies of water. The licensee stated she has no pets, no poisons and no bodies of water, no firearms, and no weapons. LPA did not observe pets, poisons, firearms, weapons, nor bodies of water. The licensee was informed that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition/firing pins must be stored separately.

At approximately 10:24 a.m. LPA Rivera observed the required 2A10BC fire extinguisher located in the kitchen and the valve on the green area indicating fully charged and serviced on 11/3/23. LPA observed a carbon monoxide detector and smoke alarm located in the daycare room. LPA tested the carbon monoxide and smoke alarm. LPA Rivera heard the sounds and are operable. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic wipes and located in the daycare room top cabinet. For ill isolation, licensee stated she utilizes a corner of the daycare room. LPA observed the last emergency drill conducted on 6/21/24.

At approximately 10:29 a.m., LPA Rivera inspected the play outdoor (front) area that is utilized by children for safety, comfort, and cleanliness. LPA observed the front yard to be fenced and the gates closed and with a keypad lock and self-latch. LPA observed the play equipment to be age appropriate and in a safe condition, free of sharp, no lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA Rivera did not observe high climbing equipment. LPA observed 3 sail triangles for adequate shade. For outdoor water drinking, children go inside the facility to drink water.

LPA Rivera observed licensee incorrect Red Cross First Aid/ CPR certification dated 4/20/24. LPA informed licensee the required certification is the Pediatric First Aid/ CPR. Licensee called the Red Cross instructor to notify that the card issued is incorrect and needs the Pediatric First Aid/CPR. LPA observed licensee Health and Safety certification dated 10/23/2004, and licensee has proof of immunization against Pertussis, MMR,

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: RIVAS FAMILY CHILD CARE	FACILITY NUMBER: 197415541
	VISIT DATE: 09/12/2024

NARRATIVE

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and Influenza declination. Licensee has completed the Child Abuse Mandated Reporter training dated 7/3/24.

LPA observed the postings License, LIC 9148 Earthquake Preparedness Checklist, and Pub 394 Notification of Parents Rights. LPA also reviewed children’s roster, children files including sleep logs and staff files. LPA did not observe a file for child #2 and observed the sleep log for child #1 incomplete. Licensee stated, keeps reminding parent for the forms and parent keeps on saying “tomorrow.” Last log dated 7/31/24 and child has been attending care. Licensee stated has not been completing the safe sleep logs daily because of the time and forgets. Also, LPA did not observe immunization record (TDAP, MMR, TB, Influenza, or influenza declination) for assistant. Licensee stated she forgot to request immunization record for assistant. LPA reminded licensee assistant or volunteers shall not be employed at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.

The following was also discussed with the licensee:

1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.

3. Licensee was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

4. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: RIVAS FAMILY CHILD CARE	FACILITY NUMBER: 197415541
	VISIT DATE: 09/12/2024

NARRATIVE

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5. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

6. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated

7. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

8. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

9. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

10. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

11. Smoking is prohibited in the family childcare home.

12. Children and staff records must be maintained and updated as needed and be available for review by the Department.

13. Immunization Requirement: H&S 1597.622: 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. The licensee and all adults working with children have proof of immunizations.

14. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

15. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: RIVAS FAMILY CHILD CARE	FACILITY NUMBER: 197415541
	VISIT DATE: 09/12/2024

NARRATIVE

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16. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

17. Liability Insurance was discussed; LPA advised licensee to review Title 22 Regulation 102417(m)(1) for additional information.

18. Dog(s) and/or pets are recommended to be isolated from children in care.

19. No, infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.

20. LIC 126 Checklist for Family Child Care provided and reviewed.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee Rosa Rivas 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 Family 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 Rosa Rivas and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee Rosa Rivas 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.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: RIVAS FAMILY CHILD CARE	FACILITY NUMBER: 197415541
	VISIT DATE: 09/12/2024

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee Rosa Rivas was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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

The deficiencies listed on the following page were observed by LPA Rivera and are being cited in accordance with California Code of Regulations Title 22 and Health and Safety. Three type B deficiencies are being issued today for regulations: 102425(j)(1)- 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. 102421(a)- (a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). 1597.622(a)(1)- (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. Please see attached LIC 809-D for citation.

Two Technical Violations given. 102416(c) - (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. 102418(a)- (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. Please see attached LIC 9102TV.

LIcensee request LIC forms in Spanish. LPA provided the Spanish forms.

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 Rivas.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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