Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274450199
Report Date: 06/01/2017
Date Signed 06/01/2017 12:13:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:RIOS, NATIVIDADFACILITY NUMBER:
274450199
ADMINISTRATOR:NATIVIDAD RIOSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 442-0970
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY:14CENSUS: 10DATE:
06/01/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Natividad RiosTIME COMPLETED:
12:15 PM
NARRATIVE
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LPA Janet Tse met with licensee Natividad Rios for an annual/random inspection, and also to follow up on the unusual incident occurred on 04/05/2017 whereas a child suffered a fracture in his arm due to a fall from a play structure. After reviewing the medical report, it appears that potential severe injury could have happened. The parent was not notified of the child's accident timely. LPA observed ten children including two infants with licensee and her husband. Present was also licensee's adult son. Adults living in the home are licensee, her husband, her two adult children with a 2 1/2-year-old child. Days and hours of operation are Monday to Friday 6:00am to 6:00pm.

LPA toured the inside and outside of the home. LPA observed a blocked fireplace. LPA observed stairs are barricaded from the bottom. Off limits indoor: the entire upstairs which consists of a master bedroom, master bathroom, and three bedrooms; downstairs laundry room and garage.. There are no bodies of water or firearms/weapons in the home. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Backyard is fenced. Off limits outdoor: left side yard. LPA reminded licensee that she can only have 14 children according to her license.

Fire extinguisher is size 3A40BC and filled. Smoke detector and carbon monoxide detector are operable. Home is clean and orderly with heating and ventilation for safety and comfort. LPA observed sufficient materials, toys, and play equipment for the day care children. Telephone is in working order. Children were supervised on the visit and LPA went over substitute options. LPA also discussed if licensee transports children, they are never to be left in parked vehicles.

A review of the staff records on 05/31/2017 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

LPA observed that in each child’s record has a copy of the emergency information card that contains all of the information specified by regulation. LPA observed that licensee has completed training on preventive health

Facility Evaluation Report dated 06/01/2017 to be continued on next page:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2017
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: RIOS, NATIVIDAD
FACILITY NUMBER: 274450199
VISIT DATE: 06/01/2017
NARRATIVE
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Facility Evaluation Report dated 06/01/2017 to be continued from previous page:

practices, and has current Pediatric CPR/1st Aid expiring 01/23/2018. Licensee was given the current forms for childcare. LPA discussed the immediate civil penalties for Zero Tolerance of $150 and the Healthy Beverage Act and AB633 requirements for type A violation. An updated LIC 279 Application for a Family Child Care Home License was provided to LPA during today's inspection.

Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

SB 792 Immunization Requirements was discussed with licensee. LPA observed immunization records for licensee, her husband, and her two adult children who sometimes assist with the day care, are in file.

Deficiency was cited. Notice of site visit was issued and must remain posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: RIOS, NATIVIDAD
FACILITY NUMBER: 274450199
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2017
Section Cited
102416.2(f)
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Reporting Requirements. As soon as possible but no later then the same business day, the licensee shall notify a child's parent or authorized representative regardless of the injuries or acts that affect that child as specified in Health and Safety Code Section 1597.467(a).
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Licensee shall ensure that parrents or authorized representatives are notified no later than the same business day of injuries or acts that affect the child's health and safety. Licensee shall forward a written plan of correction on methods and procedures to ensure that parents or authorized representatives are notified timely when an injury or accident that affect the child's health and safety
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On 04/05/2017, a child suffered a fracture in his arm due to a fall from a play structure. The parent was not notified of the child's accident timely.
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occurs.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2017
LIC809 (FAS) - (06/04)
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