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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845415
Report Date: 05/06/2022
Date Signed: 05/06/2022 12:41:49 PM

Document Has Been Signed on 05/06/2022 12:41 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SERNA FAMILY CHILD CAREFACILITY NUMBER:
334845415
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
05/06/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Hercilia SernaTIME COMPLETED:
12:50 PM
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On date and time listed, Licensing Program Analysts (LPAs) Aman Sharma and Laura Mejorado arrived at the facility to conduct a Case Management Licensee Initiated inspection. The licensee has applied for a capacity increase from a Small Family Child Care Home capacity of 8 to a Large Family Child Care Home capacity of 14. A Fire Clearance was granted on 4/11/2022. LPAs toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:

Normal days and hours of operation are: Monday-Friday, 6am-6pm.

OFF-LIMIT AREAS INCLUDE: Garage, Bathroom in the hallway, Room #2, Stairs and entire second floor. In the backyard, the off-limit areas are the shed and dirt ground.

· The facility is operating within the licensed capacity and appropriate ratios and appropriate supervision was provided during this inspection



· A working telephone is present and current number is on file

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were presented by the Licensee during this inspection.

· Fireplace in home has been completely eliminated.

· All toxins and hazardous items are locked and inaccessible to children.

· No Weapons present in the home. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations.

· Stairs are barricaded with a wooden gate

· Verification of control of property on file

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Laura Mejorado
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SERNA FAMILY CHILD CARE
FACILITY NUMBER: 334845415
VISIT DATE: 05/06/2022
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· Property Owner/Landlord Consent (LIC 9149)/Notification (LIC 9151) on file

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

· Mandated Reporter Training completed on 07/03/2021 and expires on 07/03/2023.

· Pediatric CPR and First Aid Card expire on 07/2023

· Health & Safety Certificate - completed on 10/21/2018

· No bodies of water found on premises 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.

· Clean, safe and age appropriate toys are provided to children in care.

· Current roster on file

· Documentation of fire and disaster drills on file – Last drill conducted on 04/11/2022

· Both, Employee's and Children’s records are complete/See Technical Violations (TV)

· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

· Resident and/or staff records reviewed on 05/06/2022 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

- LPAs discussed the safe sleep regulations with licensee as well as the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPAs 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.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Laura Mejorado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SERNA FAMILY CHILD CARE
FACILITY NUMBER: 334845415
VISIT DATE: 05/06/2022
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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

- 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.

- Licensee was also instructed to go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.



- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

The Licensee, Hercilia Serna, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

The application for a Large Family Child Care Home will be submitted for approval with a maximum capacity of 12 to 14 with parent notification.



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.

Exit interview conducted and report was reviewed with the licensee, 05/06/2022. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Laura Mejorado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
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