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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364845376
Report Date: 07/19/2023
Date Signed: 07/31/2023 10:56:19 AM

Document Has Been Signed on 07/31/2023 10:56 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:BURGOS FAMILY CHILD CAREFACILITY NUMBER:
364845376
ADMINISTRATOR:BURGOS, YOLANDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 275-0342
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 17DATE:
07/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Yolanda BurgosTIME COMPLETED:
07:10 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Aman Sharma arrived at the facility to conduct a required annual inspection. LPA toured the facility, both inside and outside. Records were reviewed, and the following was observed and/or discussed:

Normal days and hours of operation are: Monday- Friday 5:00am-12:00am, but licensee would like to change the hours to M-Sat. 8am-5:30pm. -Licensee agrees to submit an updated Application (LIC279), including hours of operation and ages served. Licensee also agrees to submit facility sketch (LIC999) for the indoor area of the home, indicating on and off limit areas of the home. These are due to licensing within 30 days of todays date.

OFF-LIMIT AREAS ARE LISTED AS FOLLOWS: Entire second floor.

· The facility was not operating within the licensed capacity and appropriate ratios-SEE LIC809D


· Appropriate supervision was being provided during this inspection

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

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector were in working order.

· The fireplace is screened off and not accessible by children.

· Hazardous items and toxins were found in multiple on-limit areas of the home-SEE LIC809D

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

· Stairs are properly barricaded to prevent access to children in care.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: BURGOS FAMILY CHILD CARE
FACILITY NUMBER: 364845376
VISIT DATE: 07/19/2023
NARRATIVE
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·Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted in prominent location of the home.

· Appropriate Mandated Reporter Training for licensee & assistants were missing - SEE LIC809D

· Pediatric CPR and First Aid Card for licensee and assistants were expired or missing-SEE LIC809D

· Health & Safety Certificate has been completed by licensee and is on file.

· No bodies of water on property 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 were available to the daycare children-SEE LIC809D

· Roster is current and on file.

· Documentation of fire and disaster drills are also on file – Last drill was conducted on: 07/07/2023

· 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

· Children’s records were complete, except infant files – SEE LIC9102

· Licensee’s file and assistants’ files were reviewed and were missing documentation-SEE LIC809D

· Resident and/or staff records reviewed 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 the facility at: Associations_Disassociations862@dss.ca.gov

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

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: BURGOS FAMILY CHILD CARE
FACILITY NUMBER: 364845376
VISIT DATE: 07/19/2023
NARRATIVE
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-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 recommend 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 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.

- 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, Yolanda Burgos confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address. Exit interview conducted and report was reviewed with the licensee, Yolanda Burgos.

A notice of site visit was given and must remain posted for 30 days. LPA Aman Sharma informed licensee Yolanda Burgos that this report dated 07/19/2023 document a Type A citation. Type A citation(s) shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Additionally, LPA Aman Sharma, informed the licensee, Yolanda Burgos to provide a copy of this licensing report dated 07/19/2023, that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 07/31/2023 10:56 AM - It Cannot Be Edited


Created By: Aman Sharma On 07/19/2023 at 05:59 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: BURGOS FAMILY CHILD CARE
FACILITY NUMBER: 364845376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.

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. Upon LPA's arrival, an infant was seen sleeping in an attachment to a crib. Attachments to cribs are prohibited per title 22 regulations. The warning label states in large letters: "SUFFOCATION HAZARD INFANTS HAVE SUFFOCATED".. LPA also observed a swing with a warning label stating it was unsafe for infants, due to being a strangulation hazard. This item was not being used at the time. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Licensee agrees to seize use of this attachment immediately. Licensee was able to remove attachment immediately. Licensee agrees to show proof of utilizing crib during daycare hours without attachment. Licensee also agrees to remove the swing and seize use of it in the daycare. Proof of pictures are due no later than POC due date.
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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LPA observed cleaners like Lysol Mold and Mildew remover, Cloralen with Bleach and accessible sharps like knives, tools including a screwdriver, and a wine bottle opener in the on-limits kitchen area. Numerous body lotions and sprays in the on-limits restroom. Laundry detergent was accessible in the on-limits garage area. There were also multiple cabinets without locks that contained more cleaning supplies, sharps and plastic bags. The shed in the backyard contained multiple poisons and hazards also did not have a lock on it. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Licensee agrees to submit proof of locked chemicals and sharps behind a locked cabinet door. Licensee also agrees to submit proof of a locked shed to licensing no later than the POC due date.
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:Aman Sharma
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 07/31/2023 10:56 AM - It Cannot Be Edited


Created By: Aman Sharma On 07/19/2023 at 05:59 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: BURGOS FAMILY CHILD CARE
FACILITY NUMBER: 364845376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(a)(3)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 1 out of 2 of the cribs did not have a tight fitted sheet on the mattress. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Licensee agrees to submit POC: proof of fitted sheet on mattress by POC due date.
Type A
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, LPA observed a pillow, 2 blankets, baby sandals and two head wraps in the attachment to the crib the infant was sleeping in. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Licensee agrees to submit written proof of understanding of Safe Sleep Regulations to licensing no later than the POC due date.
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:Aman Sharma
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 07/31/2023 10:56 AM - It Cannot Be Edited


Created By: Aman Sharma On 07/19/2023 at 05:59 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: BURGOS FAMILY CHILD CARE
FACILITY NUMBER: 364845376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Upon LPA's arrival, LPA counted 17 children in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Licensee agrees to submit a schedule for each child, including their name, DOB, days and hours they will be coming to the daycare. This is due to licensing no later than POC due date.
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:Aman Sharma
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 07/31/2023 10:56 AM - It Cannot Be Edited


Created By: Aman Sharma On 07/19/2023 at 05:59 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: BURGOS FAMILY CHILD CARE
FACILITY NUMBER: 364845376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above in 3 out of 3 persons. Licensee and both assistants did not have their mandated reporter training on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee agrees to go online to mandatedreporterca.com and complete mandated reporter training for "Child Care Providers" and submit proof of certificate for 3 out of 3 individuals present during today's inspection. this is due to licensing no later than POC due date.
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, 1 staff was missing CPR/first aid and the other 2 had expired certificates. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Licensee agrees to submit proof of enrollment for her and one other assistant no later than POC due date. Upon completion, licensee will submit certificates.
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:Aman Sharma
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
Page: 7 of 13
Document Has Been Signed on 07/31/2023 10:56 AM - It Cannot Be Edited


Created By: Aman Sharma On 07/19/2023 at 05:59 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: BURGOS FAMILY CHILD CARE
FACILITY NUMBER: 364845376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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3
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 persons. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee agrees to submit proof of missing immunization's for 2 out of 3 staff. Licensee was provided with missing immunization's. This is due to licensing no later than POC due date.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
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: Time of each 15-minute check

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. There were no 15 minute sleep logs for any of the infants in care. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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Licensee agrees to implement 15 minute sleep logs the very next day of the operation of the daycare, including any infants in care. Infants for licensing are up to 24 months of age. Licensee agrees to submit proof of logs to licensing no later than POC due date.
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:Aman Sharma
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
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