304310918-10-14-2021-06-CC-CODM-C7SW2M-20211014165433

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304310918
Report Date: 10/14/2021
Date Signed: 10/14/2021 04:54:42 PM

Document Has Been Signed on 10/14/2021 04:54 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:	FERNANDO, ANN		FACILITY NUMBER:	304310918
ADMINISTRATOR:	FERNANDO, ANN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 875-5584
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 12	CENSUS: 12	DATE:	10/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Ann Fernando - Licensee		TIME COMPLETED:	05:10 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	An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Carmen Odom. LPA observed licensee and assistant Jinukajayo Gamaralalage, caring for a total of 12 children, which included, 3 infants, and 9 preschool children napping in the childcare. Licensee was operating within the licensed capacity as specified on license. Due to State of Emergency COVID-19, LPA observed staff and children wearing face mask, social distancing and following CDC and Department of Public Health Guidelines. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 4 adults including the licensee living in the facility. Facility Day care hours are 7:30am-5:30pm, Monday through Friday. The home is a two story home with a backroom area used for childcare. The off-limit areas are the entire upstairs, kitchen, pool, and the garage. LPA advised licensee that children should never enter these off-limit areas. During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of baby gates. Children restroom is located in the backroom childcare area, it looked clean and sanitary. There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored in the garage and inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. Continue to page 2.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FERNANDO, ANN	FACILITY NUMBER: 304310918
	VISIT DATE: 10/14/2021

NARRATIVE

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There is a fireplace in the living room, which has a glass cover and inaccessible to children in care. The home has age appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service). Licensee stated, they use an outdoor patio and backyard for outdoor play. There is a pool in the backyard that is gated and meets bodies of water regulations. LPA advised the licensee that children should be supervised at all times in the backyard.

The licensee does have a current roster of children in care. Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. LPA did not observe infants from 0-12 months present in the childcare during inspection. LPA discussed with licensee LIC 9227 Individual Infant Sleeping Plan and sleeping log.

The licensee and assistant’s Pediatric CPR/First Aid certification expired 05/2022. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee and assistant were reviewed and within compliance.
Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. Licensee and assistant had mandated reporter training certificate in file and within compliance.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

The licensee understands she must be present in the facility and must ensure children in care are always supervised.
Continue to page 3.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FERNANDO, ANN	FACILITY NUMBER: 304310918
	VISIT DATE: 10/14/2021

NARRATIVE

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Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through [email protected] in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

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.

Updated face covering guidance was provided and licensee was to continue to message the “Three W’s”: Wash your hands. Watch your physical distance. Wear a mask. This face covering guidance is for all individuals 2 years and older, except for the exceptions (child’s development, medical exemptions, etc.) that are outlined by CDPH.
Important COVID-19 resources and links were provided:
· COVID-19 Update Guidance Childcare Programs/Providers link:
https://files.covid19.ca.gov/pdf/guidance-childcare.pdf
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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FERNANDO, ANN	FACILITY NUMBER: 304310918
	VISIT DATE: 10/14/2021

NARRATIVE

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· CCLD COVID-19 Licensed childcare and facilities and provider FAQs link: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/child-care-licensing/covid-19-child-care-resources/faqs-for-licensed-child-care-facilities-and-providers
Safe, free, and effective COVID-19 vaccines are now available to everyone age 16 and up. Every Californian can sign up at myturn.ca.gov or call (833) 422-4255 to get their COVID-19 vaccine appointment.

In the areas that were evaluated, NO deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

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.

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.

Exit interview conducted and report was reviewed with the licensee Ann Fernando. A notice of site visit was given and must remain posted for 30 days.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC809 (FAS) - (06/04)

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