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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400128
Report Date: 10/28/2022
Date Signed: 10/28/2022 04:06:25 PM

Document Has Been Signed on 10/28/2022 04:06 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
198400128
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
10/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Martha LopezTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elka Chavez conducted an unannounced Case Management inspection to the above facility, LPA met with Licensee, Martha Lopez.

At 2:39 PM LPA observed child #1 in a crib in the den. LPA did not observe the mattress covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged. LPA observed a white soft plush blanket was being used as a sheet. LPA did not observe An Individual Infant Sleeping Plan LIC 9227 form and sleep log for child #1 on file. LPA observed a sleep log for child #2 and #3 on file. LPA provided technical assistance to the licensee regarding Safe Sleep during today's inspection. Licensee was advised that this is a potential health and safety risk to children in care.

The following deficiency listed on the attached LIC 809D is being cited in accordance with California Code of Regulations Title 22.

Exit interview was conducted with Licensee, Martha Lopez.



The Notice of Site Visit (LIC 9213) – 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.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Elka Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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 10/28/2022 04:06 PM - It Cannot Be Edited


Created By: Elka Chavez On 10/28/2022 at 03:32 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 198400128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2022
Section Cited
CCR
102425(c)(2)

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(c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file. (2) The Individual Infant Sleeping Plan [LIC 9227 (3/20)....This requirement is not met as evidenced by
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Licensee stated that she will make sure that she provides forms to the parents and will make sure to put the forms in her enrollment packet. Licensee will provide LPA proof of correction by POC due date.
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Based on records review LPA did observe child #1 to have an Individual Infant Sleeping Plan [LIC 9227) on file. This poses a pontential risk to Health, Safety or Personal risk to
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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:Karen Chambers
LICENSING EVALUATOR NAME:Elka Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022


LIC809 (FAS) - (06/04)
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