Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300439
Report Date: 01/05/2018
Date Signed 01/05/2018 11:13:06 AM

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:ORTIZ, GLORIAFACILITY NUMBER:
304300439
ADMINISTRATOR:ORTIZ, GLORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 534-0361
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:14CENSUS: 2DATE:
01/05/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alicia Villalba, AssistantTIME COMPLETED:
11:30 AM
NARRATIVE
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The purpose of this visit was to conduct an annual inspection to the home upon arrival LPA met with assistant who stated that licensee was had gone to the Santa Ana, Zoo with 4 day care children. Assistant stated that she had 2 infants in her care. Assistant called licensee who instructed her to provide LPA with all the required paper work. LPA conducted inspection with Assistant while licensee was out of the home.
Licensee acknowledged that there are only 4 adults living in the home no minors at this time.

Areas used by the children are the front covered patio, front yard, kitchen, dinning area, bonus room and back yard. Licensee was informed that she needs to make sure that there should be 100% supervision.

Children's bathroom was inspected located entry door to the left is clear of hazards no eminent danger at time of visit. Lpa scanned areas used by the day care children for proper storage of all detergents, cleaning compounds, medications, perfumes, shampoos, toothpaste, and sharp pointed objects. There were age appropriate toys, equipment, and materials for children.

Licensee stated there are no weapons or guns in the home. Fire extinguisher, smoke detector and a carbon monoxide detector are present in the home. Licensee stated that they are not registered with any Foster Care agency. Licensee have current CPR and First Aid valid until 08/13/2018.

Licensee met posting requirements. LPA also reviewed a sample of children's records and children's roster. Fire drill log reviewed. Licensee and assistant have the required immunization's of measles and pertussis on file. LPA reviewed that all three adults working with children had the proper vaccinations.

Continue on to next page.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Maria NevarezTELEPHONE: (714) 703-2825
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2018
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: ORTIZ, GLORIA
FACILITY NUMBER: 304300439
VISIT DATE: 01/05/2018
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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 information and form number for Individuals who are soon to be 18 years of age or older living in the home who must be fingerprinted cleared prior to presence in the facility. Live Scan tel# (800)315-4507, complete LIC9163. Criminal record clearances/exemption transfer requests (contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182) with copy of ID and LIC 508 to fax# (714)703-2831 prior to hiring staff. LPA reviewed requirements for posting Parent’s Rights poster with information regarding Megan's Law, Information regarding AB 633 and the requirements of documents to be provided to new parents. LPA advised of the new parent’s rights notification forms. LPA discussed supervision requirements, finger prints requirements, unusual incident report, children's files, ratio and capacity. The California Child Passenger Safety Law was discussed with licensee. LPA provided the licensee with the web sites www.ccld.ca.gov.The following was also discussed with licensee:
1) LPA discussed with licensee regarding Senate Bill 277 link: ttp://www.shotsforschool.org/laws/sb277faq/
2) Senate Bill 792 http://www.ccld.ca.gov/res/pdf/16APX-16.pdf.
3) A handout of A Child Care Provider's Guide to Safe Sleep discussed and provided to licensees..
4) LPA provided the link http://www.dss.cahwnet.gov/ord/entres/getinfo/pdf/ml_ccl1511.pdf
for the child care seat belt law and discussed with licensee during visit.
5) Chapter Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf . Exit interview conducted with applicant in Spanish and appeal rights procedure explained. Visit consultation was conducted in Spanish.
In the areas evaluated, no deficiencies were observed or cited per CA Code of Regulations, Title 22, and Division 12. The Notice of Site Visit was posted. Licensee were informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The licensee were provided a copy of their appeal right (LIC 9058) and their signature on this form acknowledges receipt of these rights. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Maria NevarezTELEPHONE: (714) 703-2825
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2018
LIC809 (FAS) - (06/04)
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