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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846011
Report Date: 07/07/2022
Date Signed: 07/07/2022 02:18:48 PM

Document Has Been Signed on 07/07/2022 02:18 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:MEDINA FAMILY CHILD CAREFACILITY NUMBER:
364846011
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Keren MedinaTIME COMPLETED:
02:35 PM
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On date and time listed above, Licensing Program Analyst (LPA) Justin Giese arrived at the facility to conduct a 1 year required annual inspection. LPA was granted entry by Licensee, Keren Medina. LPA toured the facility, inside and out, reviewed records, and observed and/or discussed the following:

Normal days and hours of operation are: Monday to Saturday 6:00 a.m. to 5:30 a.m. (23.5 hours a day)
OFF-LIMIT AREAS INCLUDE: Garage and the entire second floor

A review of the staff records and review of a sampling of children's records were conducted as part of this evaluation.

The inspection consisted of reviews of the following domains:

• Physical Plant
• Care and Supervision
• Facility Administration
• Records
• Staffing Ratio and Capacity
• Personal Rights
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 364846011
VISIT DATE: 07/07/2022
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• The facility is operating within the licensed capacity and appropriate ratios
• The Licensee is present in the home and has ensured that children in care are supervised at this time
• When temporarily absent from the home, the Licensee shall arrange for a substitute adult to care for and supervise children
• A working telephone is present
• Appropriate fire extinguisher, smoke detector and carbon monoxide detector is present and were tested by the applicant during this inspection.
• All hazardous items are inaccessible, this includes: detergents, cleaning compounds, medications and other items which could pose a danger to children
• Storage of poisons is inaccessible to children and locked
• No guns or weapons present as stated by the Licensee. Licensee understands all guns, weapons and ammunition must be key-locked separately and made inaccessible per Title 22 regulations.
• This is a two story home: Stairs are barricaded at this time
• Home is clean and orderly, with heating and ventilation for safety and comfort
• Safe and appropriate toys and equipment are present for both indoor and outdoor activities.
• Outdoor play areas are fenced or appropriate supervision is present
• Verification of control of property on file
• Property owner/landlord notification and consent on file
• Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
• Pediatric CPR and First Aid Card expire on 06/07/2023
• Health & Safety Certificate - completed on 04/14/2021
• There is one pool/pond located at the back of the property. The pool has a fence that has been checked by LPA and meets Title 22 Regulations. The Applicant understands that the fence to access the pool/pond must be closed and locked during child care hours. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position when not in use.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 364846011
VISIT DATE: 07/07/2022
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· Clean, safe and age appropriate toys
· Documentation of fire drills on file: Last drill 02/01/2022
· Each child’s file contains a copy of the emergency information card with required information
· Criminal record clearances are required prior to all adults living or working in a Family Child Care Home. A civil penalty of $100.00 per day the person has been present, may be assessed. All individuals subject to a criminal record review shall obtain a criminal record clearance or exemption prior to working, residing or volunteering in a licensed home. This was verified on 07/07/2022

- Current facility’s phone numbers must be on file at all times.
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills are to be conducted every six months
- Responsibilities of being a mandated reporter
- Baby walkers, bouncy seats, exersaucers and other similar items are prohibited
- The licensee is urged to visit the U.S. Consumer Product Safety Commission webpage at www.cpsc.gov to ensure that equipment purchased for the day care has not been recalled.
- Once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809/LIC9099) must also be posted for 30 days. A civil penalty of $100 per violation will be assessed for noncompliance.
- Access to forms & Regulations for Family Child Care Homes online at www.ccld.ca.gov.
- Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care

- Please subscribe to childcareadvocatesprogram@dss.ca.gov to receive Department updates. They will be sent directly to your e-mail account once you have set up an account. This website can also be accessed through www.ccld.ca.gov
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 364846011
VISIT DATE: 07/07/2022
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- The Duty Officer is available to answer questions Monday – Friday 8am-5pm at 951-782-4200
Complaint intake is available at: 1-844-LET-US-NO (1-844-538-8766).

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

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

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-and-resources/safe-sleep as an additional resource. LPA also informed licensee [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

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.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 364846011
VISIT DATE: 07/07/2022
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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 Keren Medina.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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