Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405639
Report Date: 07/10/2017
Date Signed 07/10/2017 12:37:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:MY SECOND HOMEFACILITY NUMBER:
073405639
ADMINISTRATOR:KARLA D. TORRESFACILITY TYPE:
830
ADDRESS:1011 OAK GROVE RD.TELEPHONE:
(925) 360-4598
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:24CENSUS: 17DATE:
07/10/2017
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karla TorresTIME COMPLETED:
12:45 PM
NARRATIVE
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3) LPA, Fernando Colmenares met with the Director of the Center, for a Required Three Year visit. Also present today was one teacher and four aides. The records of all of the teachers on staff were reviewed and all were found to be in order. Five of the children's records were also reviewed. Four of the staff present including the Director have Infant CPR and First Aid Certifications which are current. The parents sign-in sheets were reviewed and are complete today. The facility was toured and found to be clean. . The pantry, the classrooms and the children's bathrooms were also toured; All were found to be clean. Food is properly stored. Cleaning products are properly stored and made inaccessible to children. The center's fire drill log was also reviewed. The first aid kit was inspected. The classrooms are neat and have plenty of toys for activities. This LPA, informed the provider of the web address, (www.ccld.ca.gov) for downloading child care forms and (www.myccld.gov) to register to receive child care updates. The school playground is well equipped and padded with engineered wood fiber. Incidental Medical Services were discussed with the licensee.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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 .This facility is not providing Incidental Medical Services (IMS) at this time. A fact sheet on Assembly Bill 633 was given to the director.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Fernando ColmenaresTELEPHONE: (510) 292-7241
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2017
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MY SECOND HOME
FACILITY NUMBER: 073405639
VISIT DATE: 07/10/2017
NARRATIVE
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LPA RECEIVED AN UPDATED 500 & 610. A REVIEW OF RECORDS TODAY INDICATE THAT ALL STAFF OR OTHER INDIVIDUALS WHO REQUIRE CAREGIVER BACKGROUND CHECKS HAVE CRIMINAL RECORD & CHILD ABUSE CLEARANCES OR EXEMPTIONS.

SEE 809-D FOR DEFICIENCIES.

If you disagree with a citation or penalty, file your appeal, with the Supervisor listed on the licensing report, in writing, within 15 days from the date you received the report or penalty assessment notice.
Exit interview with Karla Torres. This report must be made available for public review upon request for three years. Licensee was provided a copy of their appeal rights(LIC9058 12/15) and their signature on this form acknowledges receipt of these rights. A site visit notice was posted.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Fernando ColmenaresTELEPHONE: (510) 292-7241
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2017
LIC809 (FAS) - (06/04)
Page: 7 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MY SECOND HOME
FACILITY NUMBER: 073405639
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2017
Section Cited
101220.(a)
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Child's Medical Assessments - (a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child. CHILD C1 ON THE CONFIDENTIAL NAMES LIST DOES NOT HAVE A MEDICAL ASSESSMENT AND HAS BEEN ENROLLED MORE THAN 30 DAYS..
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THE DIRECTOR WILL HAVE THE PARENTS OF CHILD C1 OBTAIN A MEDICAL ASSESSMENT ALONG WITH TB TEST RESULT AND MAIL THIS LPA COPIES OF THE ASSESSMENT AND TB TEST RESULTS AS PROOF OF CORRECTION BY 8/11/17.
Type B
08/11/2017
Section Cited
H&S-1596.7995
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H&S 1596.7995 (a)(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
8 EMPLOYEES DO NOT HAVE APPROPRIATE RECORDS FOR THE ABOVE IMMUNIZATIONS.
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THE DIRECTOR WILL HAVE 30 DAYS TO PROVIDE APPROPRIATE RECORDS AND INSURE THAT ALL FUTURE EMPLOYEES ARE IMMUNIZED.
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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: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Fernando ColmenaresTELEPHONE: (510) 292-7241
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2017
LIC809 (FAS) - (06/04)
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