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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313602
Report Date: 10/07/2021
Date Signed: 10/07/2021 12:11:26 PM

Document Has Been Signed on 10/07/2021 12:11 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:COTA, YOLANDAFACILITY NUMBER:
304313602
ADMINISTRATOR:COTA, YOLANDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 341-1648
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
10/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Yolanda Cota, LicenseeTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) P Rivas conducted an unannounced case management visit and reviewed the file for child who was present during visit.

The following deficiencies are Cited under Title 22 Division 12(on lic 809d)


An exit interview was conducted, appeal rights discussed and a copy given. A written appeal must be received in the CCL office within 15 days.
THE NOTICE OF SITE VISIT WAS POSTED AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS. FAILURE TO POST WILL RESULT IN A CIVIL PENALITY OF $100.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
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 10/07/2021 12:11 PM - It Cannot Be Edited


Created By: Pat Rivas On 10/07/2021 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: COTA, YOLANDA
FACILITY NUMBER: 304313602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2021
Section Cited
CCR
102425(c)

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INFANT SAFE SLEEP
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file .This requirement was not met as evidenced by Licensee's statement that she did not have a sleep plan completed. Also
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licensee will develop sleep plan with child's parent and submit a completed plan to LPA Rivas by plan of correction date
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based on review of child's file, sleep plan was not in place. This poses a potential hazard to children in care.
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Type B
10/15/2021
Section Cited
CCR102425(j)2

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INFANT SAFE SLEEP
The provider shall supervise infants while they are sleeping and adhere to the following requirements: (2)The provider shall check and document the ollowing: (A) Labored breathing.(B) Signs of distress which includes but is not limited to flushed skin color, increase in body temperature and restlessness.
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Licensee will develop form that meets regulations which documents child's sleep . A completed Form will be sent to LPA Rivas by Plan of correction
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(D) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:a. Date.b. Infant’s name.c. Time of each 15-minute check.This requirement was not met as evidenced by licensee's statement that she did not document observation of child's sleep. This poses a potential hazard to 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:Rina Lopez
LICENSING EVALUATOR NAME:Pat Rivas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2021


LIC809 (FAS) - (06/04)
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