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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304311924
Report Date: 10/08/2021
Date Signed: 10/08/2021 11:09:53 AM

Document Has Been Signed on 10/08/2021 11:09 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:OJEDA, ANTONIAFACILITY NUMBER:
304311924
ADMINISTRATOR:OJEDA, ANTONIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 770-2217
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
10/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee - Antonia OjedaTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Corral conducted an Inspection with Licensee Antonia Ojeda to address Reporting Requirements. Prior to entering the facility LPA Corral reviewed the COVID-19 Emergency Response questionnaire with Licensee. Due to COVID 19 guidelines, LPA observed Licensee wearing face mask, social distancing and following CDC and Dept of Public Health Guidelines. Upon entrance to the Facility there were 4 infants and 2 preschool children present in care with Licensee. A review of the Facility Personnel Report Summary conducted on 10/07/2021 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During the course of an investigation, LPA Corral requested a copy of an Unusual Incident Report, UIR
(LIC 624) regarding a child injury. Licensee was unable to provide a copy of the UIR. Licensee stated
she did not report the incident to the Department of the child injury because the Child did not sustain injury while in in care. Licensee was informed that Reporting Requirements state that the Licensee shall report to the Department any unusual incident that threatens the physical or emotional health or safety of any child. LPA Corral also reminded Licensee that she is a Mandated Reporter and must report any physical or emotional abuse that is suspected to have happened to a child.

Licensee failed to inform the Department of an incident that occurred where a child sustained an injury that threatens the physical or emotional health of the child, even if Licensee stated the injury did not happen in care. Licensee is being cited for 102416.2 Reporting Requirements,which states, (b) The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. (3) Health and Safety Code Section 1597.467(b)(1) provides in part: (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child."
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Eileen Corral
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: OJEDA, ANTONIA
FACILITY NUMBER: 304311924
VISIT DATE: 10/08/2021
NARRATIVE
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During the inspection Licensee was proving care to 4 infants below the age of 2 years old and 2 preschool age children that are 2 years old without an Qualified Assistant present in care. Licensee is also being cited for 102416.5 Staffing Ratio and Capacity (e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c). Licensee stated her Assistant Angelica Galindo arrived in the facility to help with children in care at 7:30AM but left the Facility at 8 AM because she had an emergency and received a call from her son's school. LPA Corral observed Assistant Angelica arrive to the Facility at 9:15 AM. Staffing and Ratio concern was corrected on site.

The facility received a Type A violation, therefore the Licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. Failure to post Type A reports for 30 days will result in a Civil Penalty of $100.00

LPA Corral provided Reporting Requirements 102416.2 Regulation along with the Small and Large Ratio and Capacity print out which shows a visual of the number and ages of children that are allowed in care when a Qualified Assistant is present in care and when they are not. Licensee was also informed she will be contacted by the Regional Office to address the citations that are being provided today.

An exit interview was conducted with Licensee Antonia Ojeda. Appeal Rights were explained. The Licensee was provided a copy of appeal rights and signature on this form acknowledges receipt of these rights. Licensee was informed 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 above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Licensee was informed Notice of Site Visit must be posted for 30 consecutive days and failure to post will result in civil penalties of $100.00.

End of Report.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Eileen Corral
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/08/2021 11:09 AM - It Cannot Be Edited


Created By: Eileen Corral On 10/08/2021 at 09:46 AM
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: OJEDA, ANTONIA
FACILITY NUMBER: 304311924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2021
Section Cited
CCR
102416.5(e)

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102416.5 Staffing Ratio and Capacity (e) If no assistant provider is present at a Large Family Child Care Home, the licensee shall comply with the capacity requirements for a Small Family Child Care Home. This requirement was not met as evidenced by:
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The licensee stated she understands when there is not an asisstant present in care, she is to operate as a Small FCCH. LPA arrived in the facility at 8:30 AM, Assistant walked in the door at 9:15 AM. Staffing and Ratio concern was corrected on site. Licensee will also submit written statement stating she ackowledges the importance of following Ratio and Capacity Refgulations.
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LPA observed Licensee caring for 4 infants below the age of 2 years old and 2 children of age 2 years old for 45 minutes before Assistant Angelica arrived. This is an immediate threat to the safety of 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:Rina Lopez
LICENSING EVALUATOR NAME:Eileen Corral
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/08/2021 11:09 AM - It Cannot Be Edited


Created By: Eileen Corral On 10/08/2021 at 10:12 AM
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: OJEDA, ANTONIA
FACILITY NUMBER: 304311924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2021
Section Cited
CCR
102416.2(b)(3)(C)

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102416.2 Reporting Requirements (b) The licensee shall report to the Department any of the events as specified in H&S Code 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the FCCH. (3) H&S Code 1597.467(b)(1) provides in part: (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child." This requirement was not met as evidenced by:
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Licensee understands the importance of reporting an unusual incident that threathens the physicalor emotional health of a child. Licensee will provide proof of Completion of the Mandated Reporter training and submit a written statement stating she understands the importance of reporting any unusual incident that threatens the physical or emotional health of a child.
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Licensee failed to inform the Department of an incident that occurred where a child sustained an injury that threatens the physical or emotional health of the child. This poses a potential risk to the safety of 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:Rina Lopez
LICENSING EVALUATOR NAME:Eileen Corral
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021


LIC809 (FAS) - (06/04)
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