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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197412055
Report Date: 01/25/2024
Date Signed: 01/25/2024 12:38:11 PM

Document Has Been Signed on 01/25/2024 12:38 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
197412055
ADMINISTRATOR:LOPEZ, LOURDESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 424-0593
CITY:SANTA CLARITASTATE: CAZIP CODE:
91387
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
01/25/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lourdes Lopez, LicenseeTIME COMPLETED:
12:45 PM
NARRATIVE
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On Thursday, January 25, 2024, Licensing Program Analyst (LPA) Mayra Rivera conducted an annual inspection and met with licensee Lourdes Lopez who guided LPA Rivera on a tour of the facility.

Family members residing in the home have been discussed with licensee and are cleared. LPA observed 7 preschool children present and assistant. LPA observed facility to be within ratio. Operating hours are Monday to Friday from 6:30 a.m. to 6:00 p.m. and care for children ages 0 to 13 years old.

This facility is a two-story home that consists of 4 bedrooms, 3 bathrooms, kitchen, living room, laundry room dining room, laundry garage and front and backyard fenced.

Areas off limits to children include- All second floor, 4 bedrooms, 2 bathrooms, laundry room, garage, and front yard.

Areas accessible to children include the bonus room (daycare) and bathroom located in the daycare room.

At approximately 9:30 a.m., LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone and landline). For ventilation, LPA Rivera observed central AC and the vents located on the ceiling. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA observed the fireplace to have a screen. During this visit, licensee stated no infants are currently enrolled.

LPA Rivera observed cleaning compounds items, stored underneath the kitchen sink, and on top of the cabinet above the oven. LPA observed a childproof lock in place, on the cabinet underneath the kitchen sink, making it inaccessible for children to open. LPA observed the knives and sharp objects stored inside top cabinet making it inaccessible for children to reach. For water drinking, licensee stated she refills children sippy cups with filtered water. The licensee stated the facility provides the meals and snacks. LPA informed

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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 01/25/2024 12:38 PM - It Cannot Be Edited


Created By: Mayra Rivera On 01/25/2024 at 11:21 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 197412055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in not conducting fire or disaster drills once every six months which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2024
Plan of Correction
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Licensee stated she will use her smoke or carbon alarm to perform the disaster drills and will conduct a drill and document before the 30 days.
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 not having staff immunization record which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2024
Plan of Correction
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Licensee stated, she will ask her assistant to submit proof of immunization record by the due date.
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:Lady King
LICENSING EVALUATOR NAME:Mayra Rivera
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2024 12:38 PM - It Cannot Be Edited


Created By: Mayra Rivera On 01/25/2024 at 11:21 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 197412055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

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
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Based on record review, the licensee did not comply with the section cited above in having the incorrect First Aid/CPR certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2024
Plan of Correction
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Licensee stated she will contact her trainer to inform the certification is incorrect and will require to re-train Pediatric First Aid/CPR certifcation by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lady King
LICENSING EVALUATOR NAME:Mayra Rivera
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 197412055
VISIT DATE: 01/25/2024
NARRATIVE
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licensee any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. Licensee stated she currently does not have any children with severe food allergies nor on medication.

At approximately 9:36 a.m., LPA Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA observed the bottom sink cabinet closed and did not observe hazard materials and observed the restroom to be in good condition. LPA reminded licensee and personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Rivera asked the licensee if there were any pets, poisons, firearms, weapons, or bodies of water. The licensee stated she has no pets, no poisons and no bodies of water, no firearms, and no weapons. LPA did not observe pets, poisons, firearms, weapons, nor bodies of water. The license was informed that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition must be stored separately.



At approximately 9:41 a.m. LPA Rivera observed the required 2A10BC fire extinguisher located in the kitchen and the valve on the green area indicating fully charged and purchased receipt dated 1/7/2024. LPA observed a carbon monoxide detector and smoke alarm located in the hallway. LPA tested the carbon monoxide and smoke alarm. LPA Rivera heard the sounds and are operable. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic wipes and located in the daycare room top cabinet. For ill isolation, licensee stated she utilizes a corner of the daycare room. LPA did not observe the emergency drill log and informed licensee, emergency drill must be conducted every 6 months.

At approximately 9:49 a.m., LPA Rivera inspected the play outdoor (backyard) area that is utilized by children for safety, comfort, and cleanliness. LPA observed the backyard to be fenced and side gates closed and with a keypad lock. LPA observed the play equipment to be age appropriate and in a safe condition, free of sharp, no lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA Rivera observed play structure equipment to be age appropriate and areas around or under high climbing equipment, are cushioned with a carpet and foam padding. For outdoor water drinking, children bring out their water bottles. LPA observed the two side doors to be closed and locked with the self-latch and observed one shed closed and locked.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 197412055
VISIT DATE: 01/25/2024
NARRATIVE
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LPA Rivera observed licensee incorrect American Heart Association First Aid/ CPR certification. LPA informed the required certification is the Pediatric First Aid/CPR certification and can be either from the Red Cross, American Heart Association or a training agency that is EMSA approved. Licensee has completed the Child Abuse Mandated Reporter (AB 1207) training dated 1/29/2022. Licensee was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

LPA also reviewed children’s roster, children files. LPA observed the files to be missing LIC 282 Affidavit Regarding Liability Insurance.

The following was also discussed with the licensee:



1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2 Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present.

3. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

4. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

5. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 197412055
VISIT DATE: 01/25/2024
NARRATIVE
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6. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

7. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

8. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B). Mandated reporter requirements were reviewed and explained.

9. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

10. Smoking is prohibited in the family childcare home.


11. Children and staff records must be maintained and updated as needed and be available for review by the Department.

12. Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children have proof of immunizations.

13. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.



14. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

15. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

16. Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 197412055
VISIT DATE: 01/25/2024
NARRATIVE
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17. Dog(s) and/or pets are recommended to be isolated from children in care.

18. No baby bouncers, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.



To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee Lourdes Lopez was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee Lourdes Lopez and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee Lourdes Lopez 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 PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 197412055
VISIT DATE: 01/25/2024
NARRATIVE
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Licensee Lourdes Lopez was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Licensee Lourdes Lopez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The deficiency listed on the following page was observed by LPA Rivera and is being cited in accordance with California Code of Regulations Title 22. One type B deficiency is being issued today for regulation 101216(f) - At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities. 102417(g)(9)(A)- (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. Health and Safety 1597.622(c)- (c) The family day care home shall maintain documentation of the required immunization's 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. Please see attached LIC 809-D for citations.


A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted, and report was reviewed with the licensee Lourdes Lopez.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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