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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019586
Report Date: 08/11/2021
Date Signed: 08/11/2021 03:08:39 PM

Document Has Been Signed on 08/11/2021 03:08 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
198019586
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
08/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Sandra Hernandez, LicenseeTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Thelma Razo conducted a Required - 1 Year inspection and met with Licensee Sandra Hernandez. LPA stated the purpose of the inspection and together with Licensee, guided analyst on a tour of the facility. Per Licensee, there were three adult family members living in the home with one minor. LPA observed four children in care, two of whom were infants.

All areas identified on the Facility Sketch were inspected:
Off limit areas: 2 bedrooms
Day care areas: Living room, dining area, kitchen, bathroom next to the bedrooms, family room, and outdoor play area in the backyard.

The home was inspected for safety, comfort, cleanliness, telephone service (land line available), heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Per licensee, there are no weapons, firearms. The swimming pool located in the backyard was secured with combination lock. There were safe toys, play equipment and materials observed for children. The valve on the required 2A 10BC fire extinguisher indicates it was fully charged. Smoke and carbon monoxide detector were tested and in operable condition. Licensee and assistant have current Pediatric First Aid and CPR which expires on 6/2023. Mandated Reporter Training was taken by Licensee on 3/15/2021 and by assistant on 3/16/2021.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section. When any IMS is

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Thelma Razo
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2021
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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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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019586
VISIT DATE: 08/11/2021
NARRATIVE
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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: http://www.ada.gov/childqanda.htm

SB792 (Immunization Requirements for Staff and Employees) was discussed with the Licensee. The Licensee and staff have required immunization documentation on file.

Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility. Effective January 1, 2010, licensees of family child care homes are required to ensure that at least one staff member with current training in pediatric first aid and pediatric CPR is on site at all times when children are present.

LPA reviewed and issued the LIC 311 - Forms/Records to Keep in Your Family Child Care Home.
CHILDREN’S FORMS/RECORDS, FACILITY FORMS/RECORDS and INFORMATION TO BE POSTED, Disaster drills, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal record transfer requirements, criminal record and child abuse clearances were also discussed during this visit.

LPA discussed and provided a copy of PIN 20-24-CCP Recently Approved Safe Sleep Regulations in Effect and LIC 9227 Individual Infant Sleeping Plan.

During this visit, LPA obtained Child Care Facility Roster (LIC9040) that lists all children enrolled in the day care.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Thelma Razo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019586
VISIT DATE: 08/11/2021
NARRATIVE
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Deficiencies were cited during this inspection per Title 22 Division 12 and is on LIC809-D.

The Notice of Site Visit (LIC 9213) was posted by LPA – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

An exit interview was held with Licensee, copy of this report provided together with Appeal Rights.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Thelma Razo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/11/2021 03:08 PM - It Cannot Be Edited


Created By: Thelma Razo On 08/11/2021 at 02:10 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2021
Section Cited
CCR
102417(g)(1)

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Operation of a Family Child Care Home. Fire extinguishers and smoke detectors shall meet State Fire Marshall standards. This requirement was not met as evidenced by the fire extiguisher was fully charged but no tag. Per Licensee, she does not have the receipt when it was bought. This poses a potential health and safety risk to the children in care.
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Licensee is to submit proof that she will be in compliance with the fire extinguisher requirement on or before Plan of Correction (POC) date of 8/18/2021.
Type B
08/18/2021
Section Cited
CCR
102425(j)(D)

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Infant Safe Sleep. Documentation shall be maintained in the infant’s file regarding sleeping and be available to the Department for review. It should include date, infant's name, & time of each 15-minute check. This requirement was not met as evidenced by absence of documentation for Child #1 and Child #2 regarding their sleeping as
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Licensee is to submit a plan to address the absence of documentation as specified under
102425(j)(D). POC to be submitted to LPA on or before 8/18/2021.
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mentioned in the regulation. This poses a potential health and safety risk to the 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:Brandi VanOosten
LICENSING EVALUATOR NAME:Thelma Razo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


LIC809 (FAS) - (06/04)
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