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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844263
Report Date: 06/16/2023
Date Signed: 06/16/2023 02:53:02 PM

Document Has Been Signed on 06/16/2023 02:53 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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
334844263
ADMINISTRATOR:MARTHA LOPEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 485-1726
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Rosa WoltmanTIME COMPLETED:
03:05 PM
NARRATIVE
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On June 16, 2023 and 12:10 pm, Licensing Program Analyst (LPA) Ana Noble arrived at the facility to conduct an annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed: Licensee Martha Lopez was not present however her daughter was prensent who is qualified and was operating the day-care. ·

Normal days and hours of operation are: Mon-Sat, 4am-7pm. Ages 0-13.
·Off-limit areas include: All 4 bedrooms, Garage
· The facility is licensed to have no more than 14 children as a Large FCCH and is operating within the licensed capacity and appropriate ratios.

· Appropriate supervision provided during this inspection

· A working telephone is present, and the current phone number is on file

· A fully charged fire extinguisher (2A:10BC) was observed. A smoke detector and carbon monoxide detector were present and tested by the Licensee during this inspection.

· Fireplace is properly screened to prevent access by children

· All hazardous items NOT stored inaccessible to children - Under the kitchen sink and on top of kitchen counter there was several household products containing warning label "Keep out of reach of Children".

· Toxins are locked

· Weapons are not present. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Ana Noble
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844263
VISIT DATE: 06/16/2023
NARRATIVE
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·Single story home

· Clean, safe and age appropriate toys

· Current roster on file is incomplete

· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted

· Documentation of fire and disaster drills on file – Last drill conducted on 4/22/22

· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

· Verification of control of property on file

· Children’s records are NOT complete

· Employee’s records are NOT complete

· Mandated Reporter Training-Rosa Woltman completed 6/14/2022 and Maria

· Pediatric CPR and First Aid Card expire on Rosa Woltman

· Health & Safety Certificate - completed on 11/7/2020



· Resident and/or staff records were reviewed and all adults who require caregiver background checks have received all required clearances and/or exemptions.

The licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.
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: Deborah Mullen
LICENSING EVALUATOR NAME: Ana Noble
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844263
VISIT DATE: 06/16/2023
NARRATIVE
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The Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov

The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.ca.gov



LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at ttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative 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.

Facility representative 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.

If a civil penalty has been assessed during this inspection, payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. You will receive an invoice in the mail. Do not send money until you receive your invoice. Do not send cash.

See LIC809-D for cited deficiencies.



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.

An exit interview was conducted, and this report was reviewed with the facility representative, Rosa Woltman. Appeal rights were discussed and provided during the exit interview. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Ana Noble
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2023 02:53 PM - It Cannot Be Edited


Created By: Ana Noble On 06/16/2023 at 01:44 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that several cleaning products were observed under the kitchen sink/counter containing warning label to "keep out of reach of children" the cabinet was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2023
Plan of Correction
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The assistant locked and removed all items during visit.
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in Staff #2 is not cleared and associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2023
Plan of Correction
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Licensee agrees to not have Staff #2, present at the facility until staff has been cleared and has obtained clearance and associated to this facility. Submit proof of association to the Dept. by 6/17/2023.
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:Deborah Mullen
LICENSING EVALUATOR NAME:Ana Noble
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2023 02:53 PM - It Cannot Be Edited


Created By: Ana Noble On 06/16/2023 at 01:44 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that a disaster drills have not been conducted since 4/22/22, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee agrees to conduct drills with children and submit proof of completion by 6/30/2023.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in Staff #2 has not completed the required training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee agrees to have Staff #2 completed Mandated Reporter Training-General and Child Provider Training and submit proof to the Department by 6/30/2023.
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:Deborah Mullen
LICENSING EVALUATOR NAME:Ana Noble
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2023 02:53 PM - It Cannot Be Edited


Created By: Ana Noble On 06/16/2023 at 01:44 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that Staff #2 did not have any of the required immunization on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee agrees to obtain and maintain Staff #2 immunization records and submit a copy to the dept. by 6/30/23.
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 observation, interview, record review, the licensee did not comply with the section cited above in Staff 1-2 did not have proof of first aid/cpr certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee agrees to submit copies of Staff 1-2 First aid/CPR cards approved by EMSA with stickers if not from the American Heart Association or American Red Cross to the dept by 6/30/23.
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:Deborah Mullen
LICENSING EVALUATOR NAME:Ana Noble
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 06/16/2023 02:53 PM - It Cannot Be Edited


Created By: Ana Noble On 06/16/2023 at 01:44 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that Staff #2 had no file with any of the requirements which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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3
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Licensee agree to obtained and maintain all requirements for Staff #2 in file. Submit a copy to the department by 6/30/2023.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation, interview, record review, the licensee did not comply with the section cited above in Staff #2 did not have proof of the required immunizations on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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2
3
4
Licensee agree to obtained and maintain all staff immunizaiton on file and submit a copy to the Department by 6/30/2023.
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:Deborah Mullen
LICENSING EVALUATOR NAME:Ana Noble
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 06/16/2023 02:53 PM - It Cannot Be Edited


Created By: Ana Noble On 06/16/2023 at 01:44 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in Child #4-8 did no have a file with all of the required records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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2
3
4
Licensee agrees to obtain and submit Child #4-8 files to the department as proof of correction by 6/30/23.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in Child #4-8 were not listed on the facility roster, lic9040 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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2
3
4
Licensee agrees to update and add Child #4-8 to the Roster, LIC9040 and send a copy to the Department as proof of correction by 6/30/23.
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:Deborah Mullen
LICENSING EVALUATOR NAME:Ana Noble
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


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