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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845415
Report Date: 11/21/2023
Date Signed: 11/21/2023 12:07:58 PM

Document Has Been Signed on 11/21/2023 12:07 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SERNA FAMILY CHILD CAREFACILITY NUMBER:
334845415
ADMINISTRATOR:SERNA, HERCILIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 840-5635
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
11/21/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:LICENSEE HERCILIA SERNATIME COMPLETED:
12:30 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Perla Ordones arrived at the facility to conduct a required/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:

Normal days and hours of operation are: Monday – Friday; 06:00 – 06:00PM.

OFF-LIMIT AREAS INCLUDE: Entire Second Floor, Room #2, Bathroom Across from Room #2, and Garage.

The facility is operating within the licensed capacity and appropriate ratios.

· Appropriate supervision provided during this inspection.
· A working telephone is present and current number on file.
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· All hazardous items are stored inaccessible to children.
· During facility tour, LPA observed that there was debris in the on-limits backyard area. Licensee stated that the children have not been let outside recently due to the windy and chilly weather. LPA advised Licensee not to let children outside until the debris is removed.
· 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
· Stairs are barricaded.
· Verification of control of property on file.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Perla Ordones
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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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Document Has Been Signed on 11/21/2023 12:07 PM - It Cannot Be Edited


Created By: Perla Ordones On 11/21/2023 at 11:16 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SERNA FAMILY CHILD CARE
FACILITY NUMBER: 334845415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as LPA observed C1, a one year old infant, in a play yard with a cresent shaped nursery pillow inside which C1 was sleeping on which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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Licensee agreed to submit a written statement agreeing to keep play yards free of loose articles and items while infants are asleep. Licensee agrees to send proof of the Plan of Correction (POC) to Community Care Licensing (CCL) by the end of the business day on the POC due date of 12/12/2023.

It should be noted that C1 woke up and was removed from play yard during facility tour.
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 interview and record review, the licensee did not comply with the section cited above as LPA observed that Licensee had a CPR/1st Aid card which expired 07/2023 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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Licensee agrees to enroll in an EMSA approved CPR/1st Aid course by the Plan of Correction (POC) due date. Licensee agrees to send proof of the POC to Community Care Licensing (CCL) by the end of the business day on the POC due date of 12/12/2023.
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:Kimberly Williams
LICENSING EVALUATOR NAME:Perla Ordones
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/21/2023 12:07 PM - It Cannot Be Edited


Created By: Perla Ordones On 11/21/2023 at 11:16 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SERNA FAMILY CHILD CARE
FACILITY NUMBER: 334845415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as LPA observed that C1, C2, and C3 were missing proof of the 15 minute sleep check logs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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Licensee agrees to document proof of 15 minute sleep checks for C1, C2, and C3. Licensee agrees to send proof of the Plan of Correction (POC) to Community Care Licensing (CCL) by the end of the business day on the POC due date of 12/12/2023.
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:Kimberly Williams
LICENSING EVALUATOR NAME:Perla Ordones
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


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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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SERNA FAMILY CHILD CARE
FACILITY NUMBER: 334845415
VISIT DATE: 11/21/2023
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· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted. During facility tour, LPA reviewed LIC610A and noticed that Licensee was missing a second relocation site on the LIC610A. LPA advised Licensee to secure a second relocation site and revise the LIC610A. Licensee stated they would send an updated LIC610A with a second relocation site listed to Community Care Licensing.
· Mandated Reporter Training completed on 11/03/2022.
· Pediatric CPR and First Aid Card expired on 07/2023. Upon record review, LPA observed that Licensee had a CPR/1st Aid card which expired 07/2023 which Licensee confirmed was their latest certificate. Licensee stated they would enroll and attend a new CPR/1st Aid course and send proof to Community Care Licensing.
· Health & Safety Certificate - completed on 10/21/2018.
· 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.
· Violations in Infant Safe Sleep Regulations were found. Upon arrival, LPA observed C1 in a play yard with a crescent shaped nursery pillow inside which C1 was sleeping on. Licensee stated that C1 was two years old but upon record review LPA discovered that C1 was one year old. LPA brought this information to the attention of the Licensee who stated they would follow Infant Safe Sleep Regulations. It should be noted that C1 woke up and was removed from play yard during facility tour. Additionally, upon record review, LPA observed that C1, C2, and C3 were missing proof of the 15-minute sleep check logs. Licensee stated that they perform the 15-minute sleep checks but have not been recording the 15 minute checks. Licensee stated they would begin recording the 15-minute sleep checks again. Finally, during facility tour, LPA observed two sleep sacks which Licensee stated were provided by the authorized representative to utilize for infants in care. LPA did not observe any children utilizing the sleep sacks but instructed Licensee to immediately cease use of the sleep sacks as it was a violation of the Infant Safe Sleep Regulations. Licensee agreed to stop using the sleep sacks and follow the Infant Safe Sleep Regulations.
· Clean, safe and age-appropriate toys.
· Current roster on file.
· Documentation of fire and disaster drills on file – Last drill conducted on 11/03/2023.
· Children’s records are complete.
· Employee’s records are complete.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Perla Ordones
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
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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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SERNA FAMILY CHILD CARE
FACILITY NUMBER: 334845415
VISIT DATE: 11/21/2023
NARRATIVE
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· 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 11/21/2023 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

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-andresources/safe-sleep as an 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Perla Ordones
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
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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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SERNA FAMILY CHILD CARE
FACILITY NUMBER: 334845415
VISIT DATE: 11/21/2023
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at:
https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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

See LIC809-D for cited deficiencies.

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.

During the exit interview, the LICENSEE Hercilia Serna, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the Licensee Hercilia Serna.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Perla Ordones
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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