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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009483
Report Date: 03/06/2025
Date Signed: 03/06/2025 05:06:37 PM

Document Has Been Signed on 03/06/2025 05:06 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/
DIRECTOR:
HERNANDEZ, LORENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 712-1498
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
03/06/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:09 PM
MET WITH:Lorena HernandezTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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An unannounced annual/random inspection was made to the facility by Licensing Program Analyst (LPA), Cindy Castro. LPA met with Lorena Hernandez, Licensee (L1). There are currently three adults living in the home. L1 was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Childcare Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During the inspection the home was toured inside. The licensee (L1) and one (s1) staff were supervising 10 children. The facility’s operating hours are 6:00AM to 6:00PM, Monday-Friday. The floor plan submitted by the licensee was reviewed and verified. The children will have access to the converted “nursery/play room", living room, and two hallway bathrooms. The off-limits areas of the home are the garage, kitchen, two bedroom, and the office in the back yard these were made inaccessible by baby gates, door knob covers and door locking mechanisms . The home is clean and orderly at this time and will remain so during childcare hours. The children use the backyard as the outdoor play area. The backyard is completely fenced. There were no pools or other bodies of water observed in the yard. There were safe toys and equipment available for children. There is a working telephone in the home. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. Licensee stated that there are no poisons in the home. LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. The licensee conducted an emergency drill within the past six months; last drill was documented on 09/10/24. The licensee stated there are no firearms or other dangerous weapons in the home and none were observed during today's inspection. Five children's records were reviewed; emergency information was missing for C1,C2,C4 deficiency was issued. C4 was missing immunization record and CDHP286 transcription, deficiency was issued. Licensee’s CPR/First Aid expires on 10/05/26, Staff (S1) CPR/First Aid expires on 08/18/25. Licensee’s mandated reporter expires on 02/05/27 and S1 mandated reporter expires on 10/04/26. (Continue to LIC 809-C)

SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HERNANDEZ, LORENA FCCH
FACILITY NUMBER: 483009483
VISIT DATE: 03/06/2025
NARRATIVE
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LPA discussed 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 PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 03/06/25.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

The following violations of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided and discussed.

A notice of site inspection was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. An exit interview was conducted and reviewed with the Licensee, Lorena Hernandez whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 05:06 PM - It Cannot Be Edited


Created By: Cindy Castro On 03/06/2025 at 04:27 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: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review at 2:35pm, LPA observed that C4 was missing immunization records and CDPH 286 transcription. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
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POC Due Date: 03/21/2025
Plan of Correction
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Licensee stated that she will request parent/ guardian of C4 for immunization records and transcribe onto CDPH286 and submit proof to the deparment by 03/21/25 via email: cindy.castro@dss.ca.gov, fax: 707-588-5099 or mail.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on childrens record review at 2:35pm, LPA observed that C1-C2 and C4 had missing or incomplete LIC700 and LIC 627 forms. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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Licensee stated that she will have parents/guardians of C1, C2 and C4 complete LIC700 and LIC627 forms and submit proof to the deparment by 03/21/25 via email: cindy.castro@dss.ca.gov, fax: 707-588-5099 or mail.
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:Erin Virrueta
LICENSING EVALUATOR NAME:Cindy Castro
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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