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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213589
Report Date: 08/21/2015
Date Signed: 03/17/2022 01:44:04 PM

Document Has Been Signed on 03/17/2022 01:44 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:LOPEZ, BERNARDITA & DOMINGOFACILITY NUMBER:
010213589
ADMINISTRATOR:LOPEZ, BERNARDITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 888-9853
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
08/21/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Bernardita LopezTIME COMPLETED:
12:55 PM
NARRATIVE
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(3) Licensing Program Analyst Diana Stephenson met with Licensee Bernardita Lopez for UNANNOUNCED RANDOM VISIT. Present for this visit was Licensee, Spouse/Assistant Domingo Lopez, volunteers Becky Lee and Eric Lee, 3 infants and 5 preschoolers. The home was toured to conduct a Health and Safety Inspection. There was a facility roster available for review. The home is two story which consists of 3 bedrooms, 2 bathrooms located on the 2nd floor; bedroom, living room, dining area, family room, garage/converted into day care room and fenced backyard located on the 1st floor. The home has heating and ventilation for safety and comfort. The OFF LIMIT AREAS are the entire 2nd floor which is barricaded by a gate by the stairs, and the bedroom on the 1st floor which will be inaccessible by closed and/or locked doors and visual supervision at all times. The ISOLATION AREA will be family room. The fenced outdoor play area is free from defects or dangerous conditions. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, carbon monoxide, working telephone, and first aid kit. The licensee CPR and First Aid certificate is expired 3/31/14. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. Licensee was advised to conduct and document fire and disaster drills at least once every six months. Licensee was reminded that exersaucers, baby walkers, bouncers, jumpers, and similar items are not allowed and that smoking is prohibited in the home during day care hours. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review. A review of staff records on 8/21/15 indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearance or exemptions.
Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov and for day care updates visit www.myccl.gov. The attached type B deficiencies are cited today and must be corrected by the due date. Appeal rights were given and discussed. An exit interview was conducted. This report must be available for public review for 3 years. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Zakiya Ali
LICENSING EVALUATOR NAME: Diana Stephenson
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2015
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 7 of 20
Document Has Been Signed on 03/17/2022 01:44 PM - It Cannot Be Edited


Created By: Diana Stephenson On 08/21/2015 at 11:37 AM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: LOPEZ, BERNARDITA & DOMINGO
FACILITY NUMBER: 010213589

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2015
Section Cited
102421(b)
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Childs Records. The licensee shall maintain, in each child’s record, a copy of the emergency information card required in Section 102417(g) (7).

OBSERVED NO EMERGENCY INFORMATION AND CONSENT FORM FOR CHILDREN IDENTIFIED AS C1, C4, AND C5.
Type B
08/31/2015
Section Cited
102419(d)
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Admission Procedures and Parental and Authorized Representative's Rights

At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home
Notification of Parents’ Rights, LIC 995A (8/06),
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the Caregiver Background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

OBSERVED NO PARENTS RIGHTS ON FILE FOR CHILDREN IDENTIFIED AS C1, C4, AND C5.
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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:Zakiya Ali
LICENSING EVALUATOR NAME:Diana Stephenson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2015
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2015


LIC809 (FAS) - (06/04)
Page: 8 of 20
Document Has Been Signed on 03/17/2022 01:44 PM - It Cannot Be Edited


Created By: Diana Stephenson On 08/21/2015 at 11:00 AM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: LOPEZ, BERNARDITA & DOMINGO
FACILITY NUMBER: 010213589

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2015
Section Cited
102423(a)(2)
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102423(a)(2) Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations, furnishing and equipment.

UPON LPA'S ARRIVAL, AN INFANT WAS IN A CAR SEAT IN THE FAMILY ROOM.
Type B
08/31/2015
Section Cited
102416(c)
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Personnel Requirements. 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. OBSERVED LICENSEE'S CPR/FIRST EXPIRED ON 3/31/14 WHICH WAS VERIFIED BY LICENSEE.
Type B
08/31/2015
Section Cited
102417(g)(9)A1
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Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill.

OBSERVED FIRE AND DISASTER DRILLS WERE NOT CONDUCTED AND DOCUMENTED WHICH WAS VERIFIED BY LICENSEE.
Type B
08/31/2015
Section Cited
102418(g)
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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.

OBSERVED CHILD IDENTIFIED AS C8 DID NOT HAVE IMMUNIZATION RECORDS.
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:Zakiya Ali
LICENSING EVALUATOR NAME:Diana Stephenson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2015
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2015


LIC809 (FAS) - (06/04)
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