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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213589
Report Date: 02/06/2019
Date Signed: 03/17/2022 01:44:06 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: DATE:
02/06/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:LOPEZ, BERNADITA, LICENSEETIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Redmond, arrived at the facility to conduct an unannounced, ANNUAL/RANDOM health and safety inspection visit. During the inspection, LPA met with Licensees, LOPEZ, BERNARDITA & DOMINGO. Ms. Domingo accompanied LPA during the inspection. Mr. Domingo assisted LPA by obtaining some documents and answering various questions.

LPA inspected all areas of the facility accessible to children and reviewed some records. LPA observed deficiencies. The deficiencies were documented and Plan of Corrections (POC) issued on the LIC 809 D pages. Licensee is required to post a Notice of Site Visit for 30 days and Facility Evaluation Report in entrance to facility. Below, is a summary of the inspection.

Capacity/Staffing: The facility operates as a Family Day Care, with a capacity of 12. Currently, there are eight (8) children in care. There are three (3) staff persons present. The facility meets capacity and staffing requirements.

Facility description: Residential, two-story home. Classroom/multipurpose room. Kitchen. Restroom. Private bedrooms and bath. Garage. Back yard/Outdoor play area.

Accessibility: The facility has designated “On Limit” and “Off Limit” areas. These designated areas determine which areas are accessible or inaccessible to children in care, respectively. The On and Off Limit areas are further described below:

"On Limit" Areas:

· Classroom/multipurpose room (garage): there are adequate age and appropriate toys, furniture, equipment and other supplies. - CONTINUED-
SUPERVISORS NAME: Antranette Robinson
LICENSING EVALUATOR NAME: Geneen Redmond
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2019
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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: LOPEZ, BERNARDITA & DOMINGO
FACILITY NUMBER: 010213589
VISIT DATE: 02/06/2019
NARRATIVE
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Training/Records: A review of records determined: Deficiency: CPR/First Aid training for both Licensees and staff person, E. Lee, expired on 09/12/2017. There were no personnel records on file for E. Lee. There is no evidence of Mandated Reporter training for either staff. Licensees are unaware of Safe Sleep Requirements. LPA discussed with Licensees

Posted as required: Facility License, Emergency Disaster Plan, Notification of Parent's Rights. Not posted as required: If You See Something, Say Something, Advisory Given.

Staff Immunization: Deficiency: No record of current Immunization for both Licensees and staff person, E. Lee.

DEFICIENCIES AND PLAN OF CORRECTIONS (POC’S) WERE ISSUED DURING THIS VISIT. SEE LIC 809 D PAGES. APPEAL RIGHTS GIVEN. POC’S MUST BE CLEARED BY POC DUE DATE OR LICENSEE IS SUBJECT TO CIVIL PENALTY ASSESSMENT. SEND POC’S TO ATTN: LPA REDMOND. FAX TO (510) 622-2641.

Exit interview conducted. This Facility Evaluation Report discussed with the Licensee and signature obtained below. A Notice of Site Visit was issued and must remain posted for 30 days. This Facility Evaluation Report shall remain on file for 3 years.

REMINDERS/RESOURCES

· Criminal Background Clearance: All assistants, volunteers, frequent adult visitors, adults living in the home (adults are individuals 18 years of age or older) must be fingerprint cleared and associated to the facility prior to be in the presence of children in care. Failure to comply, requires an immediate civil penalty of $100 to $3000 per person, per incident
· CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: [email protected]
· NEW LAW: Safe Sleep Regulations: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing/Public-Information-and-Resources/Safe-Sleep
· Licensees and all staff are Mandated Reporters and are required to report to CCLD suspected child abuse
· CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov
· Licensees may register to receive child care updates: www.myccl.ca.gov
-CONTINUED
SUPERVISORS NAME: Antranette Robinson
LICENSING EVALUATOR NAME: Geneen Redmond
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2019
LIC809 (FAS) - (06/04)
Page: 14 of 20
Document Has Been Signed on 03/17/2022 01:44 PM - It Cannot Be Edited


Created By: Geneen Redmond On 02/06/2019 at 01:52 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2019
Section Cited
CCR
102417(g)(3)

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Where children are less than five years old are in care, stairs shall be fenced or barricaded. LICENSEE FAILED TO MEET THIS REQUIREMENT. LPA OBSERVED THAT STAIRS WERE NOT FENCED OR BARRICADED. IN ADDITION, A LADDER 5FT+WAS PROPPED AGAINST THE STAIRS.
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LICENSEE WILL KEEP STAIRS FENCED OR BARRICADED AND WILL PROVIDE EVIDENCE OF COMPLIANCE TO LPA BY POC DUE DATE.
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THIS IS AN IMMEDIATE SAFETY RISK TO CHILDREN IN CARE.
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Type B
02/27/2019
Section Cited
CCR102416(c)

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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. LICENSEE FAILED TO MEET THIS REQUIREMENT. LPA OBSERVED
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LICENSEE WILL PROVIDE EVIDENCE OF CURRENT, PEDIATRIC CPR/FIRST AID TRAINING FOR: BERNADITA & DOMINGO LOPEZ AND ERIC LEE TO LPA BY POC DUE DATE.
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THAT FIRST AID/CPR WAS EXPIRED ON 9/12/17 FOR BOTH LICENSEES AND STAFF PERSON E. LEE.
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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:Antranette Robinson
LICENSING EVALUATOR NAME:Geneen Redmond
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2019


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


Created By: Geneen Redmond On 02/06/2019 at 01:41 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2019
Section Cited
CCR
102417(g)(4)

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Operation of a Family Child Care Home. Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger to children shall be stored where they are inaccessible to children. LICENSEE FAILED TO MEET THIS REQUIREMENT. LPA OBSERVED: IN KITCHEN
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LICENSEE WILL: SUBMIT A WRITTEN PLAN/STATEMENT FOR CONTINUED COMPLIANCE. LICENSEE WILL REMOVE ITEMS AND SUBMIT EVIDENCE OF COMPLIANCE TO LPA BY POC DUE DATE.
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TWO KNIVES, AND ONE SCISSOR ON THE KITCHEN COUNTER. PINE SOL ON THE KITCHEN TABLE AND ACCESSIBLE TO CHILDREN. THIS IS AN IMMEDIATE THREAT TO THE SAFETY OF CHILDREN IN CARE.
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Type A
02/07/2019
Section Cited
CCR102417(g)(4)

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Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger to children shall be stored where they are inaccessible to children. LICENSEE FAILED TO MEET THIS REQUIREMENT. LPA OBSERVED: IN RESTROOM: WINDEX (ON COUNTER),
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LICENSEE WILL: SUBMIT A WRITTEN PLAN/STATEMENT FOR CONTINUED COMPLIANCE. LICENSEE WILL REMOVE ITEMS AND SUBMIT EVIDENCE OF COMPLIANCE TO LPA BY POC DUE DATE.
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LYSOL (ON TOILET), NEIL MED SINUS RINSE AND COLOR BRILLIANCE (ON TOP, RIGHT DRAWER, VANITY). THIS IS AN IMMEDIATE THREAT TO THE SAFETY OF CHILDREN IN CARE.
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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:Antranette Robinson
LICENSING EVALUATOR NAME:Geneen Redmond
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2019


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


Created By: Geneen Redmond On 02/06/2019 at 02:27 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2019
Section Cited
CCR
102416.1(a)(b)

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Personnel records shall be maintained on each employee and shall contain specified information. LICENSEE FAILED TO MEET THIS REQUIREMNT. LPA OBSERVED: NO RECORDS ON FILE FOR STAFF PERSON, E. LEE.
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LPA PROVIDED LICENSEE WITH A LIST OF ALL REQUIRED FORMS FOR STAFF PERSONS. LICENSEE WILL HAVE REQUIRED FORMS AVAILABLE AS REQUIRED AND PROVIDE EVIDENCE OF COMPLIANCE TO LPA BY POC DUE DATE.
Type B
02/27/2019
Section Cited
CCR
1597.622(a)(1)

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(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. Each employee and volunteer shall receive an influenza vaccination between August 1
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LICENSEE WILL PROVIDE EVIDENCE OF IMMUNIZATION FOR BOTH LICENEES AND MR. LEE TO LPA BY POC DUE DATE.
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and December 1 of each year. LICENSEE FAILED TO MEET THIS REQUIREMENT: LPA OBSERVED NO CURRENT VACCINATION RECORDS FOR BOTH LICENSEES OR STAFF PERSON E. LEE.
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Type B
02/27/2019
Section Cited
CCR
102418(g)

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Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. LICENSEE FAILED TO MEET THIS REQUIREMENT. LPA OBSERVED, IMMUNIZATION RECORDS FOR CHILD (C1) ARE INCOMPLETE: POLIO (2 DOSE), DTP (3-4) MMR (1).
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LICENSEE WILL OBTAIN EVIDENCE OF CURRENT IMMUNIZATIONS AND UPDATE FACILITY RECORDS. LICENSEE WILL PROVIDE EVIDENCE OF COMPLIANCE TO LPA BY POC DUE DATE.
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:Antranette Robinson
LICENSING EVALUATOR NAME:Geneen Redmond
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2019


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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: LOPEZ, BERNARDITA & DOMINGO
FACILITY NUMBER: 010213589
VISIT DATE: 02/06/2019
NARRATIVE
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On Limit" Continued:

· Kitchen: is also used as a sleeping area for the children. Deficiencies were cited: Two knives, and a pair of scissors (kitchen). Pine Sol, (table). ZEP Hardware & Laminate Spray (speaker near hall).

· Restroom (one) for children’s use. Deficiencies: Windex (bathroom counter), Lysol on toilet, Neil Med Sinus Rinse and Color brilliance stain remover (located in vanity cabinet, top, right, drawer). Toilet and sink are in working order. There are sanitary items available.

· Backyard/Outdoor play area (gated): Deficiencies: LPA asked Ms. Lopez to accompany LPA outside for inspection of the back yard. Although the kitchen slide door was located directly in front of where LPA and Ms. Lopez were standing, Ms. Lopez asked LPA to use an alternate exit (the garage side door). As LPA came around the side of the house, LPA observed Ms. Lopez attempt to install a padlock on the storage shed. LPA asked Ms. Domingo to open the shed. LPA observed the following deficiencies: Miracle Gro, Rustoleum, Kingsford Lighter Fluid, Charcoal and multiple, chemicals, cleaners and other hazardous items within the shed.

"Off Limit" Areas: · Upstairs: Deficiency: no gate barricading the stairs, some children in care under 5 years of age. A ladder, at the foot of steps. Living Room (except entry).

Emergency Preparedness/Safety: Licensees and one staff present at the time of inspection, have criminal background clearances and are associated to the facility. Smoke and carbon monoxide detectors are available and were tested by Fire Department, LPA observed Fire Personnel leave, and viewed report . Fully charged fire extinguisher, with a proper classification (3-A:40-B:C). Emergency Disaster Plan is posted and dated 08/21/15. Per Licensee, the plan is current. Fire and Earthquake drills were last conducted on 09/05/2018 and meet six (6) month requirement. First aid supplies available. Working telephone. There are no pools, hot tubs or other bodies of water. There are no firearms present, Per Licensee. LPA observed that the sleep areas for infants do not meet the new Safe Sleep regulations. A link to Safe Sleep information provided at the end of this report. Advisory given and discussed with Licensee. The Licensee is not currently providing Incidental Medical Services (IMS) for children in care. - CONTINUED-
SUPERVISORS NAME: Antranette Robinson
LICENSING EVALUATOR NAME: Geneen Redmond
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2019
LIC809 (FAS) - (06/04)
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