Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312394
Report Date: 08/17/2017
Date Signed 08/17/2017 10:50:31 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:HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTOFACILITY NUMBER:
304312394
ADMINISTRATOR:AREVALO ESPERANZAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 415-9125
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:14CENSUS: 4DATE:
08/17/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Ascencion Hernandez-Arevalo, LicenseeTIME COMPLETED:
11:00 AM
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An inspection was conducted at the facility by Licensing Program Analyst (LPA) Port. A review of staff records indicates that all adult residents or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently 2 adults living in the home. During today’s inspection the home and grounds were toured and the licensee was operating within the licensed capacity. There was 1 infant and 3 preschool age children being cared for by the licensee. During LPA's inspection a therapist from Behavioral Healthworks arrived for a scheduled session with one of the day care children. Operating hours are 23 hours per day, 7 days per week. The floor plan was verified. Off limits areas are made inaccessible by means of baby gates. The laundry room, garage, kitchen, main dining room, and 2 bedrooms are off limits. The main day care areas are a bedroom converted as a day care room and day care dining room. The licensee's pediatric CPR/First Aid certification is current, which expires 09/26/2017. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Poisonous items are locked in the garage. There is a working carbon monoxide detector, smoke detector, and fire extinguisher in the home. The licensee has a current roster of children in care. The facility has conducted an emergency drill within the past six months. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's visit. The children use the side yard as the outdoor play area, and it is completely fenced. The outdoor play area is free from hazards. Children's records were reviewed for parents' rights and blue California Immunization Card, and in substantial compliance. 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 . Proof of immunization against pertussis and measles for licensee was reviewed and within compliance of SB 792. Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Wendy PortTELEPHONE: (714) 703-2815
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2017
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: HERNANDEZ-AREVALO ASCENCION E & AREVALO ROBERTO
FACILITY NUMBER: 304312394
VISIT DATE: 08/17/2017
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A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the facility representative.
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf

There were no Title 22 deficiencies cited during today's inspection.

Report was reviewed and discussed in Spanish. Notice of Site Visit was posted during the visit. 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. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Wendy PortTELEPHONE: (714) 703-2815
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2017
LIC809 (FAS) - (06/04)
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