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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623873
Report Date: 01/25/2023
Date Signed: 01/25/2023 10:08:30 AM

Document Has Been Signed on 01/25/2023 10:08 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:JIMENEZ, MELINAFACILITY NUMBER:
343623873
ADMINISTRATOR:JIMENEZ, MELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 247-2530
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Melina JimenezTIME COMPLETED:
10:45 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
Licensing Program Analyst (LPA) Amanda Blesi met with Licensee, Melina Jimenez, for the purpose of an unannounced required 1-year inspection. Licensee's Mother and Father in Law were also present and live in the home. At 8:30 a.m. LPA observed a total census of 6 day care children in care including three infants.

At 9:00 a.m., Licensee guided LPA on a tour of the facility, and a health and safety inspection was conducted in all areas accessible to children. Off-limits areas include downstairs in law suite and entire 1st level, master bedroom/bathroom, rear driveway and area beyond fenced play area in backyard. Licensee acknowledged that children must never enter these areas. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Per Licensee, there are no weapons in the home .There is an in-ground pond in the backyard surrounded by a wooden slat fence that is at least 5 feet high. The gate could not be checked during today's inspection due to the ground was flooded from the recent storms. LPA will make a return visit to verify gate will self close and self latch. LPA observed a corner of the front yard, away from the children's play area, where water has formed a large puddle the size of a small shallow pond due to the recent rain storms. Licensee states the backyard is off limits and children are not allowed outside until the water reabsorbs into the ground. Toxic and hazardous items are inaccessible to children. Fireplace is barricaded to prevent access by children. Stairs were barricaded on the back patio to prevent access to children. Outdoor play space is fenced. Licensee states no new residents have moved into the home since the last inspection.

Licensee 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.

A current roster is being maintained and fire and disaster drills are documented. Current CPR and First Aid certification could not be verified today. LPA observed AB1207 Mandated Reporter Certificate is current.

(Report continues LIC809-C)
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: JIMENEZ, MELINA
FACILITY NUMBER: 343623873
VISIT DATE: 01/25/2023
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
26
27
28
29
30
31
32
LPA discussed the safe sleep regulations with licensee 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 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

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 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

One Type B deficiency was issued today. See LIC 809-D for deficiency.

Exit interview conducted and report was reviewed with the licensee Melina Jimenez.
A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/25/2023 10:08 AM - It Cannot Be Edited


Created By: Amanda Blesi On 01/25/2023 at 09:47 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: JIMENEZ, MELINA
FACILITY NUMBER: 343623873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in when current first aid/CPR could not be verified which poses a potential health, safety or personal rights risk to persons in care if not corrected.
POC Due Date: 02/08/2023
Plan of Correction
1
2
3
4
Licensee states she has taken the class but could not find proof of completion during today's inspection. To correct the deficiency, licensee shall submit a copy of a current first aid/CPR card to LPA by 2.08.23.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Keven Peters
LICENSING EVALUATOR NAME:Amanda Blesi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3