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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312850
Report Date: 01/12/2022
Date Signed: 01/12/2022 02:26:05 PM

Document Has Been Signed on 01/12/2022 02:26 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:PEREYRA, JOSE & OROZCO, LAURENCIAFACILITY NUMBER:
304312850
ADMINISTRATOR:PEREY,JOSE & OROZ, LAURENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 737-3537
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
01/12/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Licensees, Jose Pereyra and Laurencia OrozcoTIME COMPLETED:
02:40 PM
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On 01/12/2022 at 12:41 PM Licensing Program Analyst, Stella Gutierrez conducted a case management legal Non compliance inspection at Pereyra, Jose & Orozco Laurencia Family Child Care for the purpose to ensure the facility substantial compliance in accordance with Title 22 regulations and Health & Safety Code standards. Upon arrival LPA was met by Licensees Jose Pereyra and Laurencia Orozco. Based on a review of the facility roster all adults present today have obtained a criminal record clearance and are associated to the facility.

During today's case management inspection LPA, Gutierrez was a provided a tour of the facility inside and out by Licensee, Laurencia Orozco. LPA, Gutierrez observed 4 children in care ( 1 Infant and 3 Preschool age children). Facility is operating within ratio and capacity limitations. Fire extinguisher located in kitchen are with purchase receipt on 07/13/2021 and Carbon monoxide and smoke detectors in operable condition LPA, Gutierrez did not observe any immediate risks or potential hazards during the tour provided.

LPA, Gutierrez reviewed Licensees administration to be complete and meets the requirements that include:
Pediatric CPR/First aide completed on 03/19/2021 for both Licensees.
Mandated Reporter Training completed on 06/13/2021 for both Licensees.
Preventative Health & Safety Practices certification on 06/13/2021 for both Licensees.
Immunization records complete for both Licensees.
LPA, Gutierrez observed required posting in a prominent area at the facility including a fire drill/disaster log with last drill conducted in November 2021.

Licensee stated that hours of operation are Monday - Friday 7:00 AM 0 6:00 PM.

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PEREYRA, JOSE & OROZCO, LAURENCIA
FACILITY NUMBER: 304312850
VISIT DATE: 01/12/2022
NARRATIVE
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A review of 4 children's records were reviewed that included:
Admission agreement
Immunization records with PUB 286 Blue cards
LIC 700 (Identification and Emergency information
LIC 627C Consent for emergency medical treatment for ADULT AND ELDERLY RESIDENTIAL FACILITY'S the wrong form in all 4 children's files.
LIC 9150 Parental Notification additional children in care
LIC 995A Parent's Rights Notice (Signed and top portion provided to Parent)
LIC 9224 Acknowledgement of Receipt of Licensing Reports observed and signed by parent in each child's file.
Infant sleep log provided in infant file observed,

Safe Sleep
LPA, Gutierrez discussed the safe sleep regulations with licensees 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 licensees 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.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations a Type B deficiency is being cited today. Please see 809 D.


An exit interview was conducted, a copy of this report, notice of site visit and appeal rights were discussed and provided to Licensees Jose Pereyra and Laurencia Orozco.

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/12/2022 02:26 PM - It Cannot Be Edited


Created By: Stella Gutierrez On 01/12/2022 at 02:00 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PEREYRA, JOSE & OROZCO, LAURENCIA
FACILITY NUMBER: 304312850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2022
Section Cited
CCR
102417(g)(7)

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102417 Operation of a Family Child Care Home
(g) (7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number..... physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
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Licensees agree to have the parents of each of the 4 children present today complete the LIC627 and submit copies to LPA, Gutierrez via email to [email protected] by 01/18/2022 no later than 5:00 PM .
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This requirement was not met as evidence by; records review. Child #1, Child #2, Child #3 and Child #4 had the wrong form signed by the parents of the children in care. This can pose immediate risk to the children in care in the event of a medical emergency occurring at the facility.
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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:Patricia Magana
LICENSING EVALUATOR NAME:Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2022


LIC809 (FAS) - (06/04)
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