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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313678
Report Date: 04/19/2022
Date Signed: 04/28/2022 09:13:57 AM

Document Has Been Signed on 04/28/2022 09:13 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:RIVAS, SUSHAYLAFACILITY NUMBER:
304313678
ADMINISTRATOR:RIVAS, SUSHAYLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 317-2105
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 7DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sushayla Rivas, LicenseeTIME COMPLETED:
01:30 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA), Alanna Gontarek. LPA observed licensee Sushayla Rivas and Licensee's (2) Assistants, Irma Aizpurucueva and Teresa Saad caring for 7 children; which included (4) infants and (3) preschool age. Per Licensee has 11 children enrolled. Licensee was operating within the licensed capacity as specified on license.

This is a two-story home which consists of 3 bedrooms, 3 bathrooms, kitchen, dining room, 2 living rooms, nap room, front yard, balcony, 2 upstairs play areas, garage and backyard (fenced). Daycare areas include: Kitchen, nap room, one downstairs bathroom, daycare room, living room, back yard, and dining room areas. LPA observed that there is a fireplace in the daycare room and is barricaded by a glass screen. Per Licensee, areas off limits to children and parents include: Garage, upstairs 3 bedrooms, two upstairs bathrooms, balcony, 2 upstairs play areas, and front yard. Upstairs is made inaccessible via baby safety gate. Garage is made inaccessible via lock. Per licensee, provides food for children in care. There are no pets on the premises.

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.

The licensee states that 2 additional adults and 2 children currently live in the home. Per Licensee, she currently has one assistant (licensee's mom). All adults present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in the licensed child care home. Licensee states that there are no firearms stored in the home.



All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is telephone service via a cellphone that is used and the cellphone stays at the facility during operation hours. There is ventilation and heating (central). The following was observed and reviewed during this inspection.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: RIVAS, SUSHAYLA
FACILITY NUMBER: 304313678
VISIT DATE: 04/19/2022
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Poisons, detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children via child safety latches. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock. The restroom that children use was observed to be safe and sanitary.
Fireplaces and open face heaters are inaccessible to children. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 8/2/2021, as indicated on service tag. Smoke and carbon monoxide detectors were tested and are operable.

The home is observed to be clean and orderly. Where children less than five years old are in care, stairs are fenced or barricaded. LPA observed a child safety gate which keeps stairs inaccessible to children. There are toys available for children. Appropriate sleeping arrangements and cribs were observed. LPA observed 4 Pack N' Plays, 1 crib, 1 changing table, rocking chair in the middle of sleeping equipment, and 2 cots. Per Licensee, Licensee or licensee's assistants sit in rocking chair during duration of infant sleep, and will alternate sitting in the chair when breaks are needed between the Licensee and assistants. LPA inspected the kitchen. LPA observed knives to be stored in an upper cabinet. Cleaning compounds were observed to be latched in a cabinet beneath the sink. Per Licensee, other cleaning compounds are stored in a key locked cabinet in the garage. LPA inspected the day care room, and observed 2 high chairs, one feeding chair, and one baby swing. LPA observed all electrical outlets to have covers.

Currently, children are using the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that can pose a danger to children on the outdoor yard. The licensee states that supervision is always provided. There are no bodies of water on the premises.

The licensee has a current roster of children in care. Children’s records for children present during visit were reviewed. LPA observed a copy of the emergency information (LIC 700) containing all the information specified by regulation and found to be in compliance. During record review, at 12:00 p.m., LPA observed the licensee and both licensee's assistant's Pediatric CPR/First Aid certification expired 2/2022.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, 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. Proof of immunization against pertussis, influenza, and measles for licensee and assistants were reviewed and within compliance.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
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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: RIVAS, SUSHAYLA
FACILITY NUMBER: 304313678
VISIT DATE: 04/19/2022
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Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. LPA observed that the Licensee and assistant do have proof of the Mandated Reporter AB 1207 compliant Child Care Training Certificate on file. Licensee and Assistants completed training on 4/7/2022 and 4/8/22; expiring 4/7/24, and 4/8/24.

All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Last Disaster Drill was conducted on 4/4/22, and last Fire Drill was last conducted on 3/31/22. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted.

LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories. These items are not permitted in a family child care facility.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.
The licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training.

CCLD website was provided to licensee to access regulations, updates, and licensing forms. Per Licensee, is signed up to receive important Provider Information Notices (PIns). LPA also advised Licensee to: childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.

A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee. LPA issued a Confidential Names List (LIC 811) to the licensee which documents staff and children’s files reviewed during this inspection.

Licensee states that infants sleep in the nap room, where they are constantly supervised. Per Licensee, infant sleep is documented. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
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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: RIVAS, SUSHAYLA
FACILITY NUMBER: 304313678
VISIT DATE: 04/19/2022
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additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the licensee.
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf (IF SPANISH) Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdfAAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspxNIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping

The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

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

LPA advised the licensee to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov.
Capacity Handout (Small & Large) was provided during this inspection. LPA explained and provided the Records to Be Kept in the Home (LIC 311D form) as well.

Based on LPAs observations, record reviews and interviews the following violation was observed and is being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 1, Section 102416(c), is being cited on the attached LIC 809D.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
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: RIVAS, SUSHAYLA
FACILITY NUMBER: 304313678
VISIT DATE: 04/19/2022
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Exit interview conducted and report was reviewed with the licensee Sushayla Rivas. Appeal Rights and deficiency was discussed. The licensee was provided a copy of their appeal rights (LIC 9058) 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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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/process.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2022 09:13 AM - It Cannot Be Edited


Created By: Alanna Gontarek On 04/19/2022 at 12:27 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: RIVAS, SUSHAYLA
FACILITY NUMBER: 304313678

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, at 12:00 p.m., LPA observed Licensee and both Licensee's assistants to have expired CPR and Pediatric First Aid, expired on 2/2022. The licensee did not comply with the section cited above in 3 out of (3) total count persons did not have CPR/First Aid, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Per Licensee, Licensee and both Assistants will complete CPR and First Aid training and submit proof of completion via email to LPA Gontarek by the due date of 4/26/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Patricia Magana
LICENSING EVALUATOR NAME:Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


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