<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700475
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:27:56 PM

Document Has Been Signed on 04/14/2022 04:27 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:SERRANO FAMILY CHILD CAREFACILITY NUMBER:
197700475
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Edna SerranoTIME COMPLETED:
04:42 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Justin Dorsey met with Licensee Edna Serrano, who guided analyst on a tour of the facility for the One Year Required Inspection. This is a one story, 4 bedroom, 2 bathroom home with kitchen, dining room, family room, living room, and garage. There is no pool on the premises. Upon arrival LPA observed 5 children with the licensee.

Physical Plant: Main care is provided in the living room and one bedroom. Children use the bathroom in hallway near the main care area. Children have access to the living room and on-limits bedroom. Off limit areas include 3 of the homes bedrooms, kitchen, dining room, family room and garage. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (locked under sink), medicines (top cabinet in kitchen) and hazardous items (locked in top kitchen cabinet) that can pose a danger to children. Fireplace is screened. The home has safe and age appropriate toys, play equipment and materials. The smoke detector and carbon monoxide detector, and Fire Extinguisher (2A10BC) are in operable condition. LPA Dorsey reminded licensee that the fire extinguisher must be serviced every year. Per Licensee no one smokes in the home. Electrical outlets are inaccessible. There is a designated area for ill children as necessary in the family room. Per Licensee there are no weapon/firearms in the home. During the visit LPA Dorsey observed a infant swing in the home, LPA Dorsey observe the licensee remove the swing from the main care area. LPA advised licensee that the swing shall not be used by children in care.

The last fire/earthquake drill was completed 04/01/22. Roster complete and maintained current.

Bathroom: Shower/tub are free of hazards (child care bathroom). Toilet and faucet is clean and operable.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 04/14/2022 04:27 PM - It Cannot Be Edited


Created By: Justin Dorsey On 04/14/2022 at 03:51 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: SERRANO FAMILY CHILD CARE
FACILITY NUMBER: 197700475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
1
2
3
4
Per licensee Adult #1 will be removed out of the home by POC due date 04/15/22.
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:Claretta Yates
LICENSING EVALUATOR NAME:Justin Dorsey
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SERRANO FAMILY CHILD CARE
FACILITY NUMBER: 197700475
VISIT DATE: 04/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Kitchen: LPA observed that kitchen to be made inaccessible by gate. Per licensee children do not have access to the kitchen. Sharp utensils are inaccessible. Breakfast, AM snack, lunch, PM snack, and dinner are provided to the children. LPA reminded licensee If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. Cleaning supplies are kept locked under the sink. No chemicals in the kitchen were observed to be accessible.

Outdoor: The backyard is safe for children The backyard is completely fenced. The backyard has concrete for children to play. LPA observed the toys in the backyard to be in safe condition.

Advisory/Other: First Aid kit was readily available. The licensees CPR/First Aid is up to date and expires 03/16/22. Mandated Reporter was completed 03/29/21. Children nap on mats and cribs in the main care area and on limits bedroom.

Documents discussed: Safe Sleep PIN 20-24-CCP.

During the inspection LPA Dorsey found through interview and observation that Adult #1 was not fingerprint cleared. Per licensee Adult #1 arrived 04/13/22 and was visiting until 04/16/22. Per licensee Adult #1 will be removed from the home 04/14/22. A civil penalty of $200.00 will be assessed 04/14/22.

Upon receipt of a Type A deficiency, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.


Licensee Serrano 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.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SERRANO FAMILY CHILD CARE
FACILITY NUMBER: 197700475
VISIT DATE: 04/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA discussed the safe sleep regulations with Licensee Serrano 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 Serrano 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.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Licensee Edna Flores.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4