<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213589
Report Date: 03/02/2017
Date Signed: 03/17/2022 01:44:05 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:
03/02/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Bernardita LopezTIME COMPLETED:
10:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
(1) Licensing Program Analyst (LPA) Paul Petersen met with licensee Bernardita Lopez for an unannounced random site inspection. Present for this visit were licensee, spouse Domingo Lopez, assistant Erik Lee, and eight children in care consisting of one infant and seven preschoolers. The home was toured to conduct a Health and Safety Inspection. The off limits areas remain unchanged from the most recent inspection and were inaccessible by closed doors or child safety gating and visual supervision at all times. There are stairs at this home with child safety gating at the base. The home is clean with heating and ventilation for safety and comfort. There is a fully fenced outdoor play area available to children with direct supervision present at all times. There are no pools, hot tubs or any other accessible bodies of water. All hazardous materials and toxins are kept out of the reach of children. There are ample age appropriate toys that appear to be safe and in good condition. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. A review of the facility and children's records was done including the disaster drill log and the facility roster. All required forms are posted and visible for public review. Licensee has current CPR and First Aid which expires 07/2017. This facility is in ratio today. 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 Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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

The attached type B deficiency is cited today and must be corrected by the due date. An exit interview was conducted. Licensee was provided a copy of their appeal rights. A notice of site visit was provided by LPA and must remain posted for 30 days. This report must be available for public review for 3 years.

SUPERVISORS NAME: Anika Evans
LICENSING EVALUATOR NAME: Paul Peterson
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 11 of 20
Document Has Been Signed on 03/17/2022 01:44 PM - It Cannot Be Edited


Created By: Paul Peterson On 03/02/2017 at 10:33 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: 03/02/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2017
Section Cited
ยง1597.622
1
2
3
4
5
6
7
(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.

LPA observed that this facility does not have the required immunization records for staff/adults providing care to children.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Anika Evans
LICENSING EVALUATOR NAME:Paul Peterson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2017


LIC809 (FAS) - (06/04)
Page: 12 of 20