Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310883
Report Date: 04/18/2016
Date Signed 04/18/2016 12:21:58 PM

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:CISNEROS LOPEZ, ANGELICA MARIAFACILITY NUMBER:
304310883
ADMINISTRATOR:CISNEROS LOPEZ, A.M.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 537-7214
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:14CENSUS: 9DATE:
04/18/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Angelica Cisneros Lopez - LicenseeTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Jane Cong-Huyen met with the licensee, Angelica Maria Cisneros Lopez, for a Annual Random visit (1). LPA toured areas of the home accessible to the children. The home consists of one story home with 4 bedrooms and 2 baths. Licensee stated that OFF LIMITS areas include: all bedrooms, garage, both side yard areas, 2 backyard sheds (with locks) and pool area. Licensee acknowledged that children may never enter these off-limit areas. The census included 11 daycare children which includes: 9 children (2 infants and 7 preschoolers) . Also present was the licensee's 1 adult assistants who also have fingerprint clearances. 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 registered with Foster Care agency but not actively. LPA observed the licensee and adult assistants' current EMSA CPR and First Aid certificates(exp: 2/14/2017), posted Parent's Rights and current disaster plan. Fireplace is blocked and children does not have access to the fireplace. Licensee stated there are no weapons in the home. Fire extinguisher, carbon monoxide and smoke detectors meet regulations. All sharp utensils and cleaning products are stored up high and/or latched or locked which are inaccessible to children in care. Fire drill log was observed. Medications are stored up high and also inaccessible to children in care. Toys appear to be safe. The backyard is fenced. The home has an in ground pool in the backyard area with fencing and self-latching gate that meets regulations. LPA advised that she must check the backyard area and close the pool gate and all other off limits area(s) before operation hours. Licensee stated that she does not allowed the daycare children to go into the pool area. LPA reminded the licensee that she must report any major changes or alterations to Licensing Office. The home has (1) pet dog with immunization documents. LPA discussed about Incidental Medical Services (IMS). She states that at this time she is not providing any IMS to any child but if in the future she needs to, she will submit a written plan to Licensing.

No deficiency cited during today's visit.
Exit interview was conducted. The Notice of Site Visit was posted. Licensee 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. LPA informed the licensee of how to access regulations and forms from CCLD websites: www.ccld.ca.gov or Myccl.ca.gov and/ or http://ccld.ca.gov/PG411.htm. 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: 04/18/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2016
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 1