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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845182
Report Date: 01/26/2022
Date Signed: 01/26/2022 11:29:10 AM

Document Has Been Signed on 01/26/2022 11:29 AM - 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
334845182
ADMINISTRATOR:HERNANDEZ, LAURAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 899-8323
CITY:COACHELLASTATE: CAZIP CODE:
92236
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
01/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Laura HernandezTIME COMPLETED:
11:38 AM
NARRATIVE
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On date and time listed, Licensing Program Analysts (LPAs) Ana Noble and Anastasia Flores arrived at the facility to conduct an annual inspection as part of a compliance review. LPA conducted COVID19 assessment. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed: ·Normal days and hours of operation are: Monday-Friday 5:00 am - 5:00 pm ·Off-limit areas include: Master bedroom/bathroom, Room 2-3, laundry room, kitchen and garage. A Fire Clearance was granted on 4/27/2020.
· The facility is operating within the licensed capacity and appropriate ratios
· Appropriate supervision provided during this inspection

· A working telephone is present and the current number is on file

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.

· Fireplace is properly screened to prevent access by children

· All hazardous items are stored inaccessible to children

· Toxins are locked

· Weapons are not present/stored according to Title 22. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

· Single story home

· Clean, safe and age appropriate toys

· Current roster on file

· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Ana Noble
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 01/26/2022 11:29 AM - It Cannot Be Edited


Created By: Ana Noble On 01/26/2022 at 10:22 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334845182

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee assistant did not comply with the section cited above in there was no proof of completion of the required mandated reporter training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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Licensee agrees to have her assistant complete the Mandated Reporter Training and submit proof to the Department by 2/25/2022.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the assistant did not have documentation/proof of a negative TB test in file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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Licensee agrees to obtain proof of a negative TB test for Licensee's assistant. Submit proof to the Department by 2/25/2022.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Ana Noble
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/26/2022 11:29 AM - It Cannot Be Edited


Created By: Ana Noble On 01/26/2022 at 10:22 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334845182

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the Assistant did not have Notice of Employee Rights form, LIC9052, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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Corrected during visit, Licensee provided LIC9052 to assistant. Assistant completed and signed during visit, form was placed in file.
Type B
Section Cited
CCR
102416.1(a)(11)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (11) A signed statement regarding their criminal record history as required by Section 102370(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that Criminal Record Statement, LIC508 was not in file for the assistant, who was present during visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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Correction during visit. Licensee provided LIC508 to assistant. Assistant completed and signed during visit, form was placed in file.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Ana Noble
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022


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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334845182
VISIT DATE: 01/26/2022
NARRATIVE
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· Documentation of fire and disaster drills on file – Last drill conducted on 1/14/2022

· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

· Verification of control of property on file

· Children’s records are complete

· Employee’s records are NOT complete

· Mandated Reporter Training completed/expired on 6/2021 for licensee, Assistant has not completed the required training.

· Pediatric CPR and First Aid Card expire on 5/16/2022, Assistant 10/2023

· Health & Safety Certificate - completed on 7/28/2018


· Resident and/or staff records were reviewed and all adults who require caregiver background checks have received all required clearances and/or exemptions.

The licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA 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 Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: [email protected]

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Ana Noble
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334845182
VISIT DATE: 01/26/2022
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The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: [email protected]

LPA discussed the safe sleep regulations with licensee, Laura Hernandez, 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 licensee [facility representative] 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.

Licensee, Laura Hernandez was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.



The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.

If a civil penalty has been assessed during this inspection, payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. You will receive an invoice in the mail. Do not send money until you receive your invoice. Do not send cash.

See LIC809-D for cited deficiencies.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Ana Noble
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 334845182
VISIT DATE: 01/26/2022
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to [email protected]. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

An exit interview was conducted, and this report was reviewed with the licensee, Laura Hernandez. Appeal rights were discussed and provided during the exit interview.



A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Ana Noble
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
LIC809 (FAS) - (06/04)
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