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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700105
Report Date: 03/09/2022
Date Signed: 03/09/2022 09:42:26 PM

Document Has Been Signed on 03/09/2022 09:42 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:MARTINEZ FAMILY CHILD CAREFACILITY NUMBER:
197700105
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 23CENSUS: 8DATE:
03/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:57 PM
MET WITH:Virginia MartinezTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA)Isabel Ortega conducted a Case Management deficiency inspection. On 2/07/2022 licensee was not able to provide staff profile with licensing requirement documentation. Staff Florencia Cox Calbac disclosed she is transporting children from school to Martinez Family child care home and is providing supervision. Staff disclosed she does not have a valid California driver’s license, auto insurance, immunization record, mandated reporter training, and CPR/First Aid. Licensee did not comply with Title 22 regulations, this poses a potential risk to the health and safety of children in care. A Type B citation is issued and attached to report.

An exit interview was conducted, a copy of this Report, Appeal Rights, and Notice of Site Visit were provided to licensee Virginia Martinez on this day.

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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 03/09/2022 09:42 PM - It Cannot Be Edited


Created By: Isabel Ortega On 03/09/2022 at 04:57 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: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 197700105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2022
Section Cited
CCR
102416.1(a)(10)

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(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
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Licensee shall maintain a profile for each employee with all Licensing required documentation. All certificates including CPR/First aid are mandated if staff will be left alone to supervise or providing transportation. Also, a valid driver's license and auto insurance is required for providing transportation to children in care.
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Based on record review the licensee did not comply with the section cited above Employee Cox disclosed she does not have mandated reported training, CPR/First aid, Driver's license, auto insurance and is providing pick ups and supervision which poses/posed a potential health, safety or personal rights risk to persons 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:Carissa Bell
LICENSING EVALUATOR NAME:Isabel Ortega
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022


LIC809 (FAS) - (06/04)
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