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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313926
Report Date: 09/01/2021
Date Signed: 09/01/2021 11:06:15 AM

Document Has Been Signed on 09/01/2021 11:06 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:PENALBA, MIRIAM & MELO, VALENTINAFACILITY NUMBER:
304313926
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/01/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Miriam Penalba/Valentina Melo, ApplicantsTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Stacy Torrence conducted a pre-licensing inspection of the facility on today’s date. LPA toured the facility with Miriam Penalba and Valentina Melo, applicants. Currently, there are four adult residents and five minor children living in the home. Applicant Miriam Penalba stated she and her husband is currently registered with a Foster Care agency and holds a foster parent license. Foster Parent license #306003982 with Our Small World Foster Family Agency.

A review of criminal clearance records on this date indicates adults who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The facility is a single-story home with three bedrooms, two bathrooms, living room, kitchen, dining room, laundry room, front yard ( fenced), backyard (fenced), and attached garage. Applicants have designated the one bathroom, living room, kitchen, dining room, and portion of backyard as part of her day-care. Applicants has designated three bedrooms, one bathroom, laundry room, front yard, portion of backyard, and garage as the off-limit areas. Applicants have placed a child proof safety gate in the hallway leading to the off-limit bedrooms and bathroom, ensuring these areas are inaccessible to the children in care. There are stairs in the outdoor activity area, applicants have placed a safety gate at the bottom of the stairs, ensuring they are inaccessible to the children in care. The portion of the backyard that is used for the daycare has a child proof safety gate separating this from the other part of the backyard. There is a lock on the laundry door, ensuring this room is inaccessible. The applicants acknowledged the children may never enter the off-limit areas, during operation hours. Control of property was verified by LPA during today’s inspection. The applicants have a cell phone, in which is used for the daycare. The applicant was informed if a cell phone is used for childcare, it must remain on the premises at all times during hours of operation. Applicants was informed and understands the home is to be free from smoking during hours of operation.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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: PENALBA, MIRIAM & MELO, VALENTINA
FACILITY NUMBER: 304313926
VISIT DATE: 09/01/2021
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The facility does have a fireplace, located in the living, which is barricaded by a locked screen, ensuring it is inaccessible to children in care. Cleaning solutions/chemicals, utensils, and sharp knives located in the kitchen, is made inaccessible by safety latches on the drawers and all sharp knives and utensils are placed in the laundry room, which is made inaccessible by a locked door. Poisons/Hazardous items are not stored on site, and none were observed. There are no bodies of water on the premises. The toys are age appropriate and in good condition for the potential ages served. Baby walkers, bouncers, jumpers, and similar items will not be used for children in care. The applicants stated there are no weapons or firearms on the premises. When firearms are present, they must be locked and stored separately from the ammunition. During today's inspection, the smoke detector and carbon monoxide were operable, and the fire extinguisher was charged.

EMSA approved Pediatric CPR and Pediatric First Aide are current for the applicants, which both expires on 08/2023 Applicant have completed the Preventative Health training, on 07/2021. Applicants has completed the Lead Poisoning Prevention Course on 07/2021.

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.

The following was discussed with applicants: Individuals who are 18 years of age or older living or working in the home must be fingerprinted cleared prior to being present in the facility. LPA provide applicant with website for Live-Scan locations oag.ca.gov/fingerprints/locations for all adult complete LIC 9163. If adult is fingerprinted cleared and associated to another facility, licensee must submit a Criminal Record Transfer Request (LIC 9182) or Exemption Transfer Request form (LIC 9188). Contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182 or LIC 9188) with copy of a valid identification issued by State or Federal Government and Criminal Record Statement (LIC 508) to fax # (714)703-2831 prior to hiring adult. Failure to complete the clearance process or license association for any adult resident or assistant will result in a civil penalty assessment against the license.
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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PENALBA, MIRIAM & MELO, VALENTINA
FACILITY NUMBER: 304313926
VISIT DATE: 09/01/2021
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LPA reviewed Unusual Incident Report (UIR) form (LIC 624B)-advised to contact Licensing Officer of the Day within 24 hours and complete the UIR within seven days by faxing LIC624B to (714)703-2831. LPA advised applicant to report to licensing any unusual incident or child absence that threatens the physical or emotional health or safety of any child or any changes to hours and days of operation and also for any changes to facility, including on/off limit areas and change in phone number.

LPA reviewed with applicant requirements of Disaster Preparedness drills (documented every 6 months). The LPA advised of Affidavit Regarding Liability Insurance (LIC 282) if did not purchase liability insurance and to maintain the form in the children's files, and Car Safety Seat pamphlet were discussed and provided to the applicant. Posting requirements which include but not limited to Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9141), Parents Rights (PUB 394), Notice of Site Visit (LIC 9213), and License (LIC 203). LPA reviewed with applicant the need to maintain records including but not limited to Children records and Staff/Adults records, (LIC 311D).



Applicant was informed of Mandated Reporter Training for self and all assistants. Department web site form was given to download forms, Title 22 regulations, and trainings on-line at http://www.ccld.ca.gov. The applicant was also informed to visit the website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.

LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

A copy of “A Child Care Providers Guild to Safe Sleep” was provided to applicant:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PENALBA, MIRIAM & MELO, VALENTINA
FACILITY NUMBER: 304313926
VISIT DATE: 09/01/2021
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NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with applicant the following safe sleep best practices:
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

Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan (LIC 9227), completed by the authorized representative. LPA discussed the Safe Sleep Frequent Asked Questionnaire and the regulations provided.

Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf.

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

The facility was in compliance for a Small Family Child Care Home with Title 22 Regulations at the time of inspection. A license will be issued after final review, in the event additional requirements are needed, the applicants will be notified.



An exit interview conducted where the report was reviewed with the applicant. Appeal Rights and the appeal rights process was discussed with the applicant. The applicant was informed all appeals must be in writing and received by the licensing office within 15 business days. The Notice of Site Visit was posted and discussed 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. The Notice of Site Visit must be posted on or adjacent to the door.

End of Report
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC809 (FAS) - (06/04)
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