304300987-3-7-2023-06-CC-PRIS-CPPUZ3-20230307150053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304300987
Report Date: 03/07/2023
Date Signed: 03/07/2023 03:02:26 PM

Document Has Been Signed on 03/07/2023 03:02 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	ALVARADO, MARIA		FACILITY NUMBER:	304300987
ADMINISTRATOR:	ALVARADO, MARIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 537-0305
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 12	CENSUS: 2	DATE:	03/07/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Maria Alvarado, Licensee		TIME COMPLETED:	03:15 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) P Rivas conducted an unannounced case management visit to continue the annual inspection commenced on 02/13/23. Upon arrival LPA met with licensee Maria Alvarado and together conducted a physical plant tour of the home. LPA viewed one infant sleeping in play yard and one infant was playing with child care assistant. Licensee states her Hours of operation are M-F from 6:00am to 6:00pm, provides snacks, and lunch. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee 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. During today's visit staff and client files were reviewed for the individuals present. LPA also conducted a physical plant tour. An interview was conducted with Licensee. LPA provided consultation regarding Safe Sleep Regulations. LPA discussed Safe Sleep Regulations. Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials Licensee states she does not provide any Incidental Medical Services.. Prior to providing any incidental medicals Services Licensee will provide plan to Community Care Licensing. . Incidental Medical Services PIN 22-02-CCP: Best Practices Related to the Provision of Incidental Medical Services in Child Care Centers and Family Child Care Homes Cont on page 2

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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 03/07/2023 03:02 PM - It Cannot Be Edited

Created By: Pat Rivas On 03/07/2023 at 02:30 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ALVARADO, MARIA	FACILITY NUMBER: 304300987
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 1 children files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2023
	Plan of Correction
1 2 3 4	Licensee will have parents complete Individual Infant sleep plan for Child #2 and provide copy to LPA by plan of correction date.

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:

Rina Lopez

LICENSING EVALUATOR NAME:

Pat Rivas

LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ALVARADO, MARIA	FACILITY NUMBER: 304300987
	VISIT DATE: 03/07/2023

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

Page 2

In the areas that were evaluated, the following deficiency was observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. ;Individual Infant Sleeping Plan 102425(c) will be cited on lic 809d

An exit interview was conducted with licensee Alvarado. Appeal Rights were explained. The Director was provided a copy of appeal rights (LIC 9058) 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the Regional Manager to the address listed.

The Notice of Site Visit was given and discussed it must be posted as required by H & S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/ection-process.

Community care Licensing website
www.cdss.ca.gov/inforesources/community-care-licensing

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4