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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444416020
Report Date: 11/03/2022
Date Signed: 11/03/2022 01:52:33 PM

Document Has Been Signed on 11/03/2022 01:52 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ORTIZ, LUCIAFACILITY NUMBER:
444416020
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 1CENSUS: 1DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lucia OrtizTIME COMPLETED:
02:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an unannounced annual inspection to the home today. LPA met with Lucia Ortiz, Licensee, and explained the nature of today's inspection to her. Days and hours of operation are Monday to Friday from 6:00 AM to 6:00 PM. Licensee stated that she, her partner Jose Luis, and her daughter Vanessa are the adults residing in the home. Present during today's inspection LPA observed an infant in care. Licensee's certification for CPR and First Aid are current and will expire on 4/10/23.
LPA toured the indoor and outdoor areas of the home during today's inspection. LPA took a picture of the Child Care Facility Roster which is current. LPA reviewed the Fire/Disaster drill log during today's visit. Last fire drill was documented on 10/04/22. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children.
LPA observed the home has a barricaded fireplace. Off limit areas in the home are the second floor and the garage. The home has a washing and dryer area located on the second floor. LPA observed there are barricaded stairs inside the home. Licensee's home has a small back yard and it is fenced.
LPA observed a fully charged 3A40BC fire extinguisher last time serviced on 10/25/22. LPA observed there are not bodies of water in the home. LPA observed the home has at least one combo smoke and carbon monoxide detector. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children. Licensee has in file immunization records for pertussis, measles, and flu vaccines for herself according with the SB792.
Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 8 children in the home at any time and the ratio (age of the children) must be observed. The Licensee states that she does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.
***********************************Report dated 11/03/22 continues in page 2.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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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Document Has Been Signed on 11/03/2022 01:52 PM - It Cannot Be Edited


Created By: Fermin Campos-Jaramillo On 11/03/2022 at 01:08 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ORTIZ, LUCIA
FACILITY NUMBER: 444416020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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 ch #5 whose file is missing a signed form LIC9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Licensee will complete form LIC9227, will obtain parent's signature and will submit a copy to Licensing Department by 11/18/22.
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:Mary Segura
LICENSING EVALUATOR NAME:Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022


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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ORTIZ, LUCIA
FACILITY NUMBER: 444416020
VISIT DATE: 11/03/2022
NARRATIVE
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Report dated 11/03/22 continues from page 1.

Department website: www.ccld.ca.gov provided to Licensee.

Licensee has completed the "Mandated Reporter" training that all Licensees and adults in contact with children are required to take in accordance with the AB1207, Licensee' training certificate will expire on 5/03/23. Licensee understands that all the adults in contact with children are required to take the training, and renew it every two years.

A review of staff records on 10/27/22 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Lucia Ortiz 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.
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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 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

Report dated 11/03//22 continues on page 3.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ORTIZ, LUCIA
FACILITY NUMBER: 444416020
VISIT DATE: 11/03/2022
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Report dated 11/03/22 continues from page 2.

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 Lucia Ortiz

The following type B deficiency was cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

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

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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