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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364845506
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:50:40 PM

Document Has Been Signed on 06/20/2023 12:50 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:CHAVIRA FAMILY CHILD CAREFACILITY NUMBER:
364845506
ADMINISTRATOR:CHAVIRA,JUANITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 938-9187
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Juanita Chavira Licensee TIME COMPLETED:
12:45 PM
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
On date and time listed, Licensing Program Analyst (LPA) Diana Brasel arrived at the facility to conduct a 1 year annual inspection as part of a compliance review. Upon arrival LPA was greeted by the Licensee. The Licensee advised LPA that she is caring for one family and they are not here this week. The licensee agreed to have the one year visit conducted on this date. 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 7:00 am - 6:00 pm.

OFF-LIMIT AREAS INCLUDE: Entire upstairs and garage.

The facility is operating within the licensed capacity and appropriate ratios


· Appropriate supervision provided during this inspection
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested during this inspection.
· Fireplace is properly screened to prevent access by children
· All hazardous items are inaccessible to children
· Toxins are locked
· No weapons present stated, per the licensee.
· Stairs are made an inaccessible by a gate.
· Verification of control of property on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training was completed on 03/30/2021. The licensee has agreed to update the Child Care Provider and take the exam for the General. Training for the General has been taken. Certificates will be submitted by 06/26/2023.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Diana Brasel
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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 5
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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CHAVIRA FAMILY CHILD CARE
FACILITY NUMBER: 364845506
VISIT DATE: 06/20/2023
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
· Pediatric CPR and First Aid Card expired 03/20/23.
· Health & Safety Certificate - completed on 05/15/11.
There is an in-ground pool with a mesh fencing and self-latching, self-closing gate. The gate meets regulations. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age-appropriate toys are present
· Current roster on file.
· Documentation of fire and disaster drills on file – Last drill conducted on 03/24/2023.
· Children’s records are complete
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: [email protected]
· Resident and/or staff records reviewed on 06/20/2023 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: [email protected]

- 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. A copy of the Safe Sleep regulations was provided on this date.

- 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.

No Incidental Medical Services being provided. Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing 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

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Diana Brasel
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CHAVIRA FAMILY CHILD CARE
FACILITY NUMBER: 364845506
VISIT DATE: 06/20/2023
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
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.

- Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at:


https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

- 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.

See LIC 809D for cited deficiency.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.


The licensee, Juanita Chavira confirmed that there are no Registered Sex Offenders living in the facility. To the best of her knowledge there is no Registered Sex Offenders using the facility address for their mailing address.

Exit interview conducted, copy of Appeal Rights provided, and the report was reviewed with the licensee Juanita Chavira.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Diana Brasel
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/20/2023 12:50 PM - It Cannot Be Edited


Created By: Diana Brasel On 06/20/2023 at 12:19 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHAVIRA FAMILY CHILD CARE
FACILITY NUMBER: 364845506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023

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 observation of the CPR & First Aid card, the licensee did not comply with the section cited above due to the card expired on 03/20/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
The licensee has agreed to enroll into an EMSA approved CPR & First Aid course no later than 06/30/2023. It was agreed upon that the updated card would be emailed to licensing upon completion.
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:Gilbert Sena
LICENSING EVALUATOR NAME:Diana Brasel
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5