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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629365
Report Date: 06/05/2023
Date Signed: 06/05/2023 02:34:17 PM

Document Has Been Signed on 06/05/2023 02:34 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:ANDRAL, EDNER FAMILY CHILD CAREFACILITY NUMBER:
376629365
ADMINISTRATOR:EDNER ANDRALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 717-4099
CITY:SAN DIEGOSTATE: CAZIP CODE:
92105
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
06/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Edner AndralTIME COMPLETED:
01:55 PM
NARRATIVE
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On June 5th, 2023, at 11:40 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted an unannounced Annual Required Inspection and met with the Licensee Edner Andral. LPA disclosed the purpose of the inspection and was granted facility entry by the Licensee. The Licensee, the roommate and four (4) children were present in the facility during this inspection; one child is the Licensee’s own child. This facility is a four (4) bedroom , three (3) bathroom, single floor house. Licensee accompanied LPA during this inspection. The following areas used for childcare are: living room, one (1) bathroom and one (1) bedroom. The off limit areas are remaining bedrooms, remaining bathrooms, and the kitchen. The kitchen is made inaccessible by use of child safety gates. The remaining bedrooms and bathrooms have door locks.

The fire extinguisher and smoke/carbon monoxide detector meet requirements. Hazardous items were observed inaccessible to children during this inspection. The Licensee has available toys, play equipment and materials. Licensee states children play in the tented side yard for outdoor activities. Licensee was reminded that continuous supervision is to be given to children whenever engaged in outdoor activities. No bodies of water were observed on the premises during the inspection. Licensee stated there are no weapons in the home.

Licensee’s First Aid and CPR certifications expire in May 2024. Licensee has required immunizations. The facility roster is not maintained. Child files were incomplete. The last fire/disaster drill was conducted and documented on 06/04/2023.

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.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: ANDRAL, EDNER FAMILY CHILD CARE
FACILITY NUMBER: 376629365
VISIT DATE: 06/05/2023
NARRATIVE
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LPA provided Licensee with Provider Information Notice (PIN) 20-24-CCP, a blank LIC 9227 “Individual Infant Sleeping Plan” form and two (2) examples of safe sleep logs. 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.

LPA reminded Licensee of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, and ensure that all adults residing or working in the home have criminal background clearances or exemptions. Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare.

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.

LPA provided Licensee with Provider Information Notices (PIN) 22-31-CCP, PIN 22-22-CCP and PIN 23-04-CCLD. PIN 22-31-CCP provides information about the new MyChildCarePlan.org website, a resource that can assist families in finding available childcare. This website provides a childcare search tool that connects parents to childcare providers and Resource and Referral Agencies throughout California. PIN 22-22-CCP notifies licensed Family Child Care Home providers about the availability of the Family Child Care Home License Incentive Payment related to COVID-19 pandemic relief. PIN 23-04-CCLD states that pre-pandemic reporting requirements now apply due to the end of the COVID 19 State of Emergency.

Deficiencies were observed as per California Code of Regulations, (Title 22, Division 12 & Chapter 3), and are being cited on the attached LIC 809-D.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: ANDRAL, EDNER FAMILY CHILD CARE
FACILITY NUMBER: 376629365
VISIT DATE: 06/05/2023
NARRATIVE
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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. Exit interview conducted and report was reviewed with the Licensee Edner Andral.

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: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/05/2023 02:34 PM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 06/05/2023 at 12:40 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: ANDRAL, EDNER FAMILY CHILD CARE
FACILITY NUMBER: 376629365

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviews, the licensee did not comply with the section cited above in three (3) out of three (3) children files lacked the emergency information card, which poses as a potential health ,safety or personal rights risk to children in care.
POC Due Date: 06/19/2023
Plan of Correction
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LPA provided Licensee with the blank emergency information form. Licensee said he will have the parents complete, date and sign. He said that he will email LPA copies of those completed forms no later than 06/19/2023.
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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/05/2023 02:34 PM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 06/05/2023 at 12:40 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: ANDRAL, EDNER FAMILY CHILD CARE
FACILITY NUMBER: 376629365

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Licensee's statement and record reviews, the licensee did not comply with the section cited above in that three (3) out of three (3) children's file did not have a completed, dated and signed LIC 995A form signed by their parent, which poses as a potential health, safety or personal rights risk to children in care.
POC Due Date: 06/19/2023
Plan of Correction
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LPA provided Licensee with four (4) blank LIC 995A forms. Licensee said he will have the parents, complete, date and sign the LIC 995A form and email LPA copies of these completed forms no later than 06/19/2023.

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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023


LIC809 (FAS) - (06/04)
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