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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009483
Report Date: 02/21/2024
Date Signed: 02/21/2024 03:27:30 PM

Document Has Been Signed on 02/21/2024 03:27 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
SANTA ROSA CC RO, 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: 7DATE:
02/21/2024
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lorena HernandezTIME COMPLETED:
03:35 PM
NARRATIVE
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On 02/21/24 a subsequent Case Management visit was made by Licensing Program Analyst (LPA), Cindy Castro, in response to an Unusual Incident Repot (UIR) that occurred on 02/15/24 which involved child (C1) being left in a parked vehicle. LPA met with licensee (L1), Lorena Hernandez, to discuss the purpose of the visit, conducted interviews with L1, Staff S1&S2 and requested facility roster of the children currently in care. The licensee self-reported the incident and submitted a UIR to the Department on 02/20/24. The report noted C1 fell asleep after picking up school age children and was accidentally forgotten in the parked vehicle on the driveway of the Child Care Home.

During the subsequent visit, LPA observed 7 children in care, upon LPA's arrival at 1:30pm. During interviews conducted at prior visit on 02/21/24, to obtain more information about UIR. Licensee and S1- S2 corroborated the absence of supervision for C1. Licensee and Staff stated that they approximated that C1 was in the parked vehicle on the driveway for 1.5 hours. Statement from Parent who found C1 in the locked vehicle also confirmed the span of time that C1 was unsupervised in the parked vehicle.

As a result of today's visit an immediate civil penalty of $500 is being assessed for incident that occurred on 02/15/24, Type A (see LIC421IM).

LPA informed the licensee to provide a copy of this licensing report dated 02/21/24 that documents any Type A citation 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.

Exit interview conducted and report was reviewed with Lorena Hernandez. Appeal Rights were provided and discussed. A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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 2
Document Has Been Signed on 02/21/2024 03:27 PM - It Cannot Be Edited


Created By: Cindy Castro On 02/21/2024 at 02:48 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: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2024
Section Cited
CCR
102417(k)(1)

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Operation of a Family Child Care Home
(k) All vehicle occupants must be secured in an appropriate restraint system.
(1) Children shall not be left in parked vehicles.
This requirement was not met as evidenced by:
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Licensee stated that she will create a parent group chat on 02/21/24 and record a video of the empty vehicle used for transportation of children and send everyday starting on 02/22/24 to asure parents no children is accidently left in vehicle. Licensee and S1-S2 will watch videos on Supervision on following website:
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Based on interviews and record reviewed the licensee did not met the requirement by leaving C1 in a locked parked vehicle for 1.5 hours on 02/15/24.
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https://ccld.childcarevideos.org/family-child-car
e-providers/ and submit a Statement of Understanding to the Department by 02/22/24.Via mail, email, or fax.
Email:cindy.castro@dss.ca.gov Fax:(707) 588-5099

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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:Alexis Hollon
LICENSING EVALUATOR NAME:Cindy Castro
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


LIC809 (FAS) - (06/04)
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