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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 574500509
Report Date: 11/01/2023
Date Signed: 11/01/2023 04:43:53 PM

Document Has Been Signed on 11/01/2023 04:43 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HERRERA, ROSAFACILITY NUMBER:
574500509
ADMINISTRATOR:HERRERA, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 640-4748
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
11/01/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Rosa HerreraTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erwin Tjhia conducted an unannounced 1 Year required inspection and met with Licensee, Rosa Herrera. LPA observed 5 children supervised by Licensee, and 1 Assistants. Licensee operation hours are Monday- Friday: 8:30 AM - 5:30 PM.

Licensee 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 Child Care 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 today, LPA was informed by licensee that one adult resident was not fingerprinted cleared and associated to the facility.

LPA and Licensee toured the facility during the inspection. Off limit areas are downstair bedroom, entire upstairs and the garage. The backyard is fenced. Licensee stated there are no weapons in the home. There are no bodies of water on the premises.

LPA conducted record reviews during the inspection. Five children's files, Licensee, and her Assistants’ files were reviewed. LPA discussed mandated reporter training with the Licensee. LPA did not observe current Mandated Reporter Training during today inspection. Licensee understands Mandated Reporter Training is to be completed every two years. Mandated reporter training can be accessed atwww.mandatedreporterca.com. LPA did not observed any CPR/First Aid certification. LPA did not observe Emergency Disaster Plan (LIC 610a) and Child Care Facility Roster (LIC 9040) at the facility during today inspection.
Report Continue on 809-c
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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Document Has Been Signed on 11/01/2023 04:43 PM - It Cannot Be Edited


Created By: Erwin Tjhia On 11/01/2023 at 03:05 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HERRERA, ROSA
FACILITY NUMBER: 574500509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in as one adult resident was not fingerprinted cleared and associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Licensee will fingerprint the adult resident as soon as possible.
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:Bettina Engelman
LICENSING EVALUATOR NAME:Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/01/2023 04:43 PM - It Cannot Be Edited


Created By: Erwin Tjhia On 11/01/2023 at 03:05 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HERRERA, ROSA
FACILITY NUMBER: 574500509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan.

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 as LPA did not observe emergency disaster plan (LIC 610a) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Licensee will submi thet emergency disaster plan (LIC 610a) to licensing/LPA.
Section Cited
Operation of A Family Child Care Home
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:Bettina Engelman
LICENSING EVALUATOR NAME:Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2023 04:43 PM - It Cannot Be Edited


Created By: Erwin Tjhia On 11/01/2023 at 03:05 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HERRERA, ROSA
FACILITY NUMBER: 574500509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

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 as LPA did not observed 15 minutes check log for an infant under 24 months during today inspection iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Licensee will submit the 15 minutes check log to the licensing/LPA.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 as LPA did not observed the current mendated report during today inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Licensee will submit the complete mandated reporter training to licensing/LPA
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:Bettina Engelman
LICENSING EVALUATOR NAME:Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/01/2023 04:43 PM - It Cannot Be Edited


Created By: Erwin Tjhia On 11/01/2023 at 03:05 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HERRERA, ROSA
FACILITY NUMBER: 574500509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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 as LPA did not observe any CPR/First Aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Licensee will submit the complete CPR/First Aid certification to licensing/LPA
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

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 as LPA did not observe Child Care Facility Roster (LIC 9040) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Licensee will submit the Facility Roster (LIC 9040) to Licensing/LPA
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:Bettina Engelman
LICENSING EVALUATOR NAME:Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


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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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HERRERA, ROSA
FACILITY NUMBER: 574500509
VISIT DATE: 11/01/2023
NARRATIVE
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LPA observed that there were no hazardous items accessible to children. LPA observed that cleaning materials were inaccessible. Fire extinguisher, smoke detector, and carbon monoxide detector meet regulation. Toys appear to be safe.

This facility doest not provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

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 did not observed 15 minutes check log for an infant under 24 months during today inspection. 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.

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.

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.

Exit interview was conducted and report was reviewed with Licensee. A notice of site visit was provided and posted by LPA and must remain posted for 30 days.

Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
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