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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400463
Report Date: 09/02/2021
Date Signed: 09/02/2021 11:24:20 AM

Document Has Been Signed on 09/02/2021 11:24 AM - 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:BERNAL FAMILY CHILD CAREFACILITY NUMBER:
198400463
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Jazel Bernal, ApplicantTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Susann Sanchez conducted a prelicensing inspection to the above facility. LPA met with Jazel Bernal, applicant who guided analyst on a tour of the facility 9:50am. Per applicant hours of operation will be 8:00am to 5:00pm, Monday to Friday.

This is a one-story home which consists of 1 bedroom, 1 bathrooms, kitchen w/ dining area, daycare room, garage, side yards, front yard and backyard (fenced). On limit areas are: day care room, the living room, kitchen (just sign in and to get to the living room), and one bathroom that is located in the hallway, and backyard. Per applicant, areas off limits to children and parents include: one bedroom, garage, front yard and side yards. All off limit rooms are were observed to be locked and side yards were gated off. The applicant will provide food children.

The applicant states that two adult currently live in the home. All individuals present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in a licensed home. Per applicant, there are no weapons, firearms and no bodies of water on the premises.

All areas identified on the facility sketch that children use, were inspected for safety, comfort, cleanliness, telephone service, ventilation and heating (central). The following was observed and reviewed during this inspection.

Detergents, cleaning compounds, medications, and other items which could pose a danger are inaccessible to children and are kept in the under the kitchen sink and garage. The licensee states that there are poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock. LPA observed locks in all kitchen cabinets. LPA observed knifes for cooking were located in a high cabinet and out of reach for children.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 198400463
VISIT DATE: 09/02/2021
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The fire extinguisher, does meet the 2A10BC standards and is located in the hallway. Fire extinguisher was serviced on 07/22/2021, as stated on the service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. Smoke and carbon monoxide detectors were tested and are operable.

The home is observed to be clean and orderly. There is heating and ventilation for safety and comfort. There are toys available for children. The applicant states that there is a cell phone is used and stays at the facility during operating hours.

The outdoor play area was observed to be fenced. At this time, children will be using the back yard for outdoor play time. The applicant states that supervision is provided at all times.

The applicant has completed training on preventive health practices including Pediatric First Aid and CPR. The applicant Pediatric First Aid and CPR expires on 07/10/2023. There are first aid supplies available.

Infant Care: Applicant states that they will care for infants. LPA advised the Licensee to sleep infants where they can be directly supervised at all times and advised against sleeping infants in a separate room. The applicant states the following as a supervision plan for infants: Infants sleep in the day care room where he will be providing supervision. LPA provided the applicant with a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. Online copy can be downloaded at: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf. LPA reviewed and gave applicant PIN 20-24: SAFE SLEEP REGULATIONS
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is 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
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 198400463
VISIT DATE: 09/02/2021
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The following was discussed with the applicant:
· 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. Civil Penalties will be assessed if not in compliance.
· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training, Immunizations (TDAP, MMR, Influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.
· Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a family child care home.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
· No infant walkers, No Johnny jumpers, No saucer chairs, and any other item that falls into that category are not permitted in the facility.
· Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
· The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.
· Isolation for Ill children: When a child is ill he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home). Per applicant, the living room will be used as an isolation area.
· Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information. Licensee states he does not have liability insurance at the moment, but states that she will once licensed.

Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee submitted proof of immunizations during prelicensing inspection..

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 198400463
VISIT DATE: 09/02/2021
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· Mandated Reporter Training: H&S 1596.8662: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com. Applicants Mandated Reporter expires on 08/09/2023

LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms:



CHILDREN FORMS/RECORDS - Children’s files must contain the following documents/information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), Consent/Verification for Nebulizer Care (LIC 9166), California School Immunization Record, Parent Notification for Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Acknowledgment of Receipt of Licensing Reports (LIC 9224).
FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records: As required in Title 22 Regulations 102416.1, Unusual incident/Injury Report (LIC 624B): Child Care Facility Roster (LIC 9040), Notice of Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108), Property Owner/Landlord Consent (LIC 9149), Property Owner/Landlord Notification Form (LIC 9149).
INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by Law to post the following:
Facility License (LIC 203), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parent’s Rights (PUB 394). A Notice of Site Visit (LIC 9213): Must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care. All posting were observed to be in the living room on the parent broad.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 198400463
VISIT DATE: 09/02/2021
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OTHER INFORMATION THAT WAS DISCUSSED:
· Never Shake a Baby, Sudden Infant Death Syndrome (SIDS) and Safe Sleeping practices
COVID, using best practices.

Per applicant, there are no dual licenses at this address.

LPA discussed Department of Public Health, Early Care and Education Guidance COVID-19 recommendations. LPA reviewed COVID-19 Self- Assessment with applicant. Per applicant, has a digital thermometer, extra face mask, and disinfectants.

Corrections: There are no corrections to be made at this time. LPA will submit application to LPM V. Cook for final approval.

Exit interview was conducted with Jazel Bernal applicant, including, but not limited to Appeal Procedures, Site Visit and Initial Appeal Rights.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC809 (FAS) - (06/04)
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