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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009483
Report Date: 06/20/2023
Date Signed: 06/20/2023 05:00:38 PM

Document Has Been Signed on 06/20/2023 05:00 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HERNANDEZ, LORENA FCCHFACILITY NUMBER:
483009483
ADMINISTRATOR:HERNANDEZ, LORENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 712-1498
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Lorena HernandezTIME COMPLETED:
05:10 PM
NARRATIVE
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An annual inspection was made to the facility by Licensing Program Analyst (LPA), Elpidia Hernandez Torres. A review of staff records on 06/20/2023 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently two adults living in the home.

During today’s inspection the home and grounds were toured. The licensee and assistant were supervising 11 children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 05:00AM to 06:00PM, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the garage, kitchen, one bedroom, and the office in the back yard , and were made inaccessible by baby gates, door locking mechanisms . The home was clean and orderly, and was at a comfortable. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire 09/2024. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. The regulation that poisons are locked with a key or combination lock was reviewed. The fireplace has been made inaccessible with furniture for toys. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection. The children use the back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard. Nine children's records were reviewed; required emergency information was missing for C2,C3,C4 deficiency was issued. Six children were missing one or more doses of vaccines deficiency.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HERNANDEZ, LORENA FCCH
FACILITY NUMBER: 483009483
VISIT DATE: 06/20/2023
NARRATIVE
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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.

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 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

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Lorena Hernandez.

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.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/20/2023 05:00 PM - It Cannot Be Edited


Created By: Elpidia Hernandez Torres On 06/20/2023 at 04:15 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HERNANDEZ, LORENA FCCH
FACILITY NUMBER: 483009483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, Six children C1,C2, C3, C4, C6, C7 were missing one or more doeses of certain vaccinations. The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2023
Plan of Correction
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LPA printed out the requirements regarding childrens vaccinations. Licensee spoke to guardians at pick up and requested updated vaccination records for children in care. LPA will return for a POC visit on or before 07/11/2023.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview,record review, Three children C2,C3, C4 did not have complete packets on file. the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2023
Plan of Correction
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LPA printed out the requirements regarding childrens files. Licensee spoke to guardians at pick up and requested they fill out the complete packet before dropping of children. LPA will return for a POC visit on or before 07/11/2023.
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:Leslie Lepori
LICENSING EVALUATOR NAME:Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/20/2023 05:00 PM - It Cannot Be Edited


Created By: Elpidia Hernandez Torres On 06/20/2023 at 04:15 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HERNANDEZ, LORENA FCCH
FACILITY NUMBER: 483009483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

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, C2 infant in care didn't have LIC 9227 on file with packet. The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2023
Plan of Correction
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LPA printed out the requirements regarding childrens files. Licensee spoke to guardians at pick up and requested they fill out the complete packet before dropping of children. LPA will return for a POC visit on or before 07/11/2023.
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:Leslie Lepori
LICENSING EVALUATOR NAME:Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
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