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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 09:42:03 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:
04:46 PM
MET WITH:Virginia MartinezTIME COMPLETED:
06:18 PM
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On 3/9/22 LPA Ortega conducted a subsequent inspection, during the tour of the facility LPA Ortega observed an infant Child#1 sleeping in a play yard with a blanket, stuffed animal(white rabbit) and a pacifier with a stuffed animal attached(giraffe). Two children were in a room with the door closed present; one infant and one toddler. Responsibility for Providing Care and Supervision for Infants was not met. Sleeping infant(s) shall be directly observed by sight and sound at all times. Staff shall physically check on sleeping infant(s) every 15 minutes and document the following: Infants up to 24 months of age. LPA observed infant check at 1:30 p.m., 2:06 p.m. then again at 2:46 p.m. when asked by LPA to check the infant room.
Two Type A deficiencies will be cited under Title 22 Regulation code 102425(1)(A) Infant Sleep and 102425 (j)(1)(2)(A)-(D)5(A), see LIC9099D Upon receipt of a type A deficiency the licensee shall post the report for 30 days in addition to the Notice of Site Visit & provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee will obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file.
An exit interview was conducted a copy of this report was provided to the licensee along with Notice of Site Visit and appeal rights.
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 05:46 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 A
03/09/2022
Section Cited
CCR
102425(1)(A)

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(1) Pacifiers shall be allowed in the crib or play yard if the following provisions are in place:

(A) There shall not be anything attached to the pacifier.
This requirement was not met by:
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licensee removed pacifier and other toys in the play yard. Licensee will review Safe sleep title 22 regulations and PIN related to safe sleep and provide an understanding of safe sleep summary to the Palmdale RO by 3/11/22 by email or fax.
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During walk through LPA observed an infant Child#1 sleeping in a play yard with a pacifier attached to a stuffed animal, blanket, and stuffed animal toy in the play yard.
This poses an immediate health and safety risk to children in care.
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Type A
03/09/2022
Section Cited
CCR102425(j)(1((2)5(A)

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(1) The provider shall physically check on the infant every 15 minutes. (D) Documentation shall be maintained in the infant’s file and be available to the Department for review. (5) If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open...
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Licensee will immediately begin 15 min log documentation for infants and keep door open during nap time or have all children in an open area during nap time to be able to provide visual supervision at all times.
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at all times. (A) The provider shall be able to visually observe the infant without moving the door. This requirement was not met by:
LPA observed children in a separate room with the door closed. Not visual observation was completed and no 15 min checks were observed. This possess an immediate risk to 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: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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