Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300987
Report Date: 10/12/2016
Date Signed 10/12/2016 10:55:33 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:ALVARADO, MARIAFACILITY NUMBER:
304300987
ADMINISTRATOR:ALVARADO, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 537-0305
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:14CENSUS: 6DATE:
10/12/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria Alvarado - LicenseeTIME COMPLETED:
11:00 AM
NARRATIVE
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LPA Jane Cong-Huyen met with licensee, Maria Alvarado, for a annual random visit (1). LPA toured all areas of the home inside and outside and areas accessible to the children. The home is a one level home with 4 bedrooms and 2 bathrooms. Licensee stated that OFF LIMITS areas include: all bedrooms except for the first left bedroom, master bath, garage, both side yard areas, laundry room and backyard shed. Licensee acknowledged that children may never enter these off-limit areas. The census includes 6 daycare children with ages ranging from 1 - 4 years old. (1 infant and 5 preschoolers) Three are the licensee's own grand child. Also present during today's visit was the licensee's assistant and her mother. Both have been fingerprint cleared. A review of family member/staff records on this date indicates that all family members and/or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee stated there are no new residents in the home since licensed. Licensee stated that she is not registered with any Foster Care agency. Licensee was able to show proof of CPR (exp:4/11/17) and First Aid (exp: 4/11/17) that is EMSA certified for herself and her brother/assistant. LPA observed posted license, Parent's Rights and current disaster plan. LPA also reviewed children's records and children's roster. The home has no fireplace. Wall heaters are screened and met regulations. Licensee stated there are no weapons in the home. LPA observed all sharp utensils, hazardous chemicals and medication are stored up high or in latched/locked cabinet which is inaccessible to children in care. Fire extinguisher, smoke and carbon monoxide detectors meet regulations. Licensee must provide 100% visual supervision when the children are in an unfenced area. The home has no pets at this time. The home has no bodies of water. LPA discussed Incidental Medical Services (IMS) with the licensee. The licensee states that she does not have any children that needs IMS at this time but if the situation changes, she will contact licensing to submit the IMS plan.
LPA also reviewed immunization records for all adults working and/or residing in the home regarding to the new SB792 for influenza, Pertussis and Measles. She states that she is aware of the new law but does not have all of the proof during today's visit. She will have to gather the proof and submit to LPA by 11/11/16.
Deficiency cited during today's visit. (See LIC809D)
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2016
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ALVARADO, MARIA
FACILITY NUMBER: 304300987
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2016
Section Cited
H&S 1597.622(c)
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Employees or volunteers at family day care home; immunization requirements; records; exemptions: The family day care home shall maintain documentation of the required immunization or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the family day care home.
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Licensee stated that she will gather all of the proof of immunization (Influenza, Pertussis & Measles) for herself, spouse, mother & assistant and will send proof to LPA by or before 11/11/16.

She states that her brother is currently out of the country and when he returns in 2018, she will get his immunization records and send to LPA.
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No proof for immunization for all adults residing and/or working in the licensed facility during today's visit.
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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: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2016
LIC809 (FAS) - (06/04)
Page: 3 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ALVARADO, MARIA
FACILITY NUMBER: 304300987
VISIT DATE: 10/12/2016
NARRATIVE
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(Random Annual, page 2)

Exit interview was conducted. Report reviewed and discussed. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Appeal rights provided and explained if violation was issues. The director/licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. LPA informed the director/licensee of how to access regulations and forms from CCLD websites: www.ccld.ca.gov or Myccl.ca.gov. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2016
LIC809 (FAS) - (06/04)
Page: 2 of 3