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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846011
Report Date: 03/14/2023
Date Signed: 03/14/2023 11:54:37 AM

Document Has Been Signed on 03/14/2023 11:54 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:MEDINA FAMILY CHILD CAREFACILITY NUMBER:
364846011
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
03/14/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Keren MedinaTIME COMPLETED:
12:00 PM
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On date and time listed above Licensing Program Analyst (LPA) Justin Giese arrived at the facility to conducted a Licensee initiated Case Management Visit for the purpose of Licensee increasing capacity to a Large Family License. Fire clearance for facilty was granted on 02/24/2023. 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 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
• There is a properly barricaded fire place
• Stairs are properly barricaded
• 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.
• 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.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 364846011
VISIT DATE: 03/14/2023
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• Outdoor play areas are fenced
• 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 06/2023
• Health & Safety Certificate - completed on 04/2021
• 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.
  • The Duty Officer is available to answer questions Monday – Friday from 8:00am to 5:00pm (951)782-4200
  • Complaint hot line is available 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 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
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
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: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 364846011
VISIT DATE: 03/14/2023
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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.

Before licensure, the following needs to be corrected/completed:
1. No corrections needed for Licensure

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Keren Medina
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC809 (FAS) - (06/04)
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