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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191213998
Report Date: 02/20/2020
Date Signed: 02/20/2020 01:00:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GERGOV FAMILY DAY CAREFACILITY NUMBER:
191213998
ADMINISTRATOR:DELKA D. GERGOVFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 845-5048
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:12CENSUS: 6DATE:
02/20/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Delka GergovTIME COMPLETED:
01:15 PM
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On 02/18/2020 at approximately 12:00 PM, Licensing Program Analyst, Stella Gutierrez met with Licensee, Delka Gergov and explained the purpose of todays visit of an Annual required inspection to ensure that facility is in compliance with Title 22 regulations and Health and Health Safety code standards. Upon arrival, LPA observed 06 children (4 INFANTS and 2 TODDLERS) being supervised by Licensee and assistant, Josephina Garibay. Facility is license for a capacity of 12 children. Facility is operating within ratio and capacity limitations. All adults observed during today’s visit are fingerprinted and associated to the facility. Licensee guided LPA on a tour of the facility inside and out. Hours of operation are from 7:30 AM to 5:30 PM, Monday through Friday. Facility is closed all major holidays.

Areas identified in the sketch and observed by LPA, Gutierrez during today’s visit:
Interior:
This is a single-story dwelling home that consists 3 bedrooms, 2 bathrooms, kitchen/dining, living room, family room and an attached garage. Guest home in back of home that utilized for children’s activities and play time. There is no pool, spa or other bodies of water on the premises. There are no weapons/Fire arms kept on the premises. Family members residing in the home include Licensee, spouse and 1 other adult. The facility was inspected inside and outside for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning when compounds, and hazardous items that can pose a danger to children.
On limits areas include: Bedroom #3, bathroom #2 and guest home. Guest home is where main care area is used for the children excluding eating and sleeping purposes. LPA observed age appropriate toys, learning materials, games and activities for children in care. All furniture was found in good repair, clean, and without hazards. is the utilized for changing and napping purposes Bedroom #3 is where the children nap.. Age appropriate napping equipment (MATS &COTS) materials available and inspected for the children. Licensee

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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998
VISIT DATE: 02/20/2020
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provides meals and snacks for the children when in care. Food is stored in refrigerator located in the kitchen, Refrigerator was inspected today. Small table and chairs observed today for the children and bumbos with eating trays for the babies. Bathroom #2 and is located through family room adjacent to bedroom #3. LPA observed the bathroom to be in operable condition and free from hazards. Bathroom has age appropriate materials and toiletries for the children to utilize.

LPA observed a working smoke detector located in main care area and bedroom #3 an operable carbon monoxide detector located in hall way area and main care area and 2A10-BC fire extinguisher in kitchen (serviced last November 2019 located in main care area and another located in kitchen area. A and a fully equipped first aid kit including, ointment, gauze, band aides, cleansing cloths and digital thermometer located in main care area.

Off-limits areas include the following: Kitchen dining room, living room, family room Bedroom #1, bedroom #2, laundry area and bathroom #1. Cleaners/chemicals are kept under kitchen sink. LPA observed the kitchen sink with a latch to make inaccessible to the children when in care. Sharp objects and knives are kept in a top tier shelf.

Exterior:

On limits areas include: Back yard only, access to the back yard is through sliding glass doors from main play area. There are two steps leading to outdoor area and licensee was advised to properly supervise the children with assistance when going outside. Inspection of the outdoor play area was conducted. Fencing around the perimeter of the back yard. LPA also observed a play house and several tyke toy bikes and cars, picnic tables for the children to use while they are playing outside. Partly shaded area for children observed in back yard.

Off limits areas include: The attached garage and front yard. LPA observed that children do not have access to these areas.

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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998
VISIT DATE: 02/20/2020
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Administration:

REQUIRED FORMS TO BE POSTED AND OBSERVED BY LPA during today’s visit in main care area


· LIC203 Facility License
· LIC 610A Emergency Disaster Plan
· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster

Documents observed today by LPA:


-Children’s roster up to date and located in main care area.
--Fire Drill log with the last fire drill conducted on 02/2020 located in main play area
Facility file:
-Pediatric First Aid and Adult, Child and Infant CPR to be current (expires on 01/20/2021) for Licensee.
-Immunization records for Licensee were available to LPA to observe today.
-Mandated reporter Training certification completed for both Licensee and Assistant on 03/13/2019
-LPA observed prior to arrival today that Annual License fees are to be current. LPA advised Licensee to continue paying annual fees timely. If paying by check, Licensee was informed to write Facility number on check.
-03 Children’s files reviewed today.
-Licensee and assist and file reviewed today

*LPA discussed capacity limitations, new car seat law, personal rights, Notification of Parent's Rights revised 12/06, inspection authority & agency's consultative role. Licensee understands this new role and was given the opportunity to discuss the agency’s new approach during today’s visit.

Smoking is prohibited on the premises of a family child care home as specified in Health and Safety Code Section 1596.795(a) The smoking of tobacco in a private residence that is licensed as a family child care home shall be prohibited during the hours of operation as a family day care home and in those areas of the family day care home where children are present.


--*The LPA also discussed earthquake safety and necessity of drills every 6 months. Page 3 of 6
SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998
VISIT DATE: 02/20/2020
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*The Licensee was also informed that all adults living in or having access to day care children in the home are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the aforementioned is not adhered to, a Civil Penalty of $100 /day per uncleared adult will be assessed.

-The facility is NOT currently providing IMS. Incidental Medical Services (IMS) policy was discussed with the Licensee. 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.html

The licensee was informed of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541.


Email Address: childcareadvocatesprogram@dss.ca.gov

Safe Sleep Links:
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx


NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

SIDS & SHAKEN BABY SYNDROME INFORMATION (discussed) flyer provided.


Consultation of safe sleep provided to Licensee today and the following was discussed:
Licensee was reminded that all infants must be placed on their backs when sleeping. LPA provided safe sleep flyer and discussed safe sleep practice. Infants must be placed on their backs and must be physically checked every 15 minutes to gauge temperature and ensure they are breathing to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to

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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998
VISIT DATE: 02/20/2020
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never shake a baby to prevent the Shaken Baby Syndrome. Licensee, DELKA GERGOV stated that she understands safe sleep practice and prevention of Shaken Baby Syndrome for infants and to ensure supervision at all times infants are in care at GERGOV FAMILY CHILD CARE facility.

The following were also discussed with licensee:



Senate Bill 792: This bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles.

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment. A copy provider rights and Appeal process provided to Licensee. All appeals must be sent to:

California Department of Social Services | Community Care Licensing Division
300 Continental Blvd., Suite 290-A
El Segundo, CA 90245

New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

Assembly Bill 1207: California Child Care Workers; Mandated Training Requirement. Beginning January 1, 2018, all licensed providers, applicants, directors and employees must complete Mandated Reported Training prior to March 30, 2018 and renew training every two years at: www.mandatedreporterca.com. Volunteers are encouraged but not required to take the training. Providers are to complete the 4-hour General Training and 3-hour Child Care Provider Training.

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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998
VISIT DATE: 02/20/2020
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Nutrition Requirement: Beginning January 1, 2016, AB 290 will require for each new license issued, at least one director or teacher at each child care center or family child care home to have at least one hour of training in the importance of childhood nutrition. This applies to anyone submitting a new application, relocating their facility, selling their facility or transferring their license. Please note this training cannot be completed online or by home study programs. The training must be taken from an Emergency Medical Services Authority (EMSA) approved training program OR an accredited college or university.

Assembly Bill 633: Upon receipt by the licensee, licensees are to provide to parents/guardians the following: Copies of any licensing reports that document a Type A citation- this includes facility visits and substantiated complaint investigations; copy of licensing documents pertaining to a conference conducted by a local licensing agency management representative and the licensee of this family child care home in which issues of noncompliance are discussed or copies of a summary of an accusation indicating the Department's intent to revoke the facility's license. Copies of any of the above licensing documents the licensee has received in the prior 12 months shall be provided to parents/guardians of newly enrolled child at the facility.

Internet address for reports, regulations: DSSNET address: http://ccl.dss.cahwnet.gov/ and for children’s and employees forms: http://www.dss.cahwnet.gov/getinfo/pubintro.html#1

Licensee currently does not receive quarterly updates and will be registered by LPA. An updated email was received during today’s visit. The facility is found to be operating within substantial compliance today’s visit. There will be no deficiencies cited today.


An exit interview was conducted and a copy of this report, appeal rights along with the notice of site visit were provided to Licensee, DELKA GERGOV.

The licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. Copies of the reports must also be provided to each parent when a serious deficiency, Type A, is cited (LIC9224). Page 6 of 6

SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020
LIC809 (FAS) - (06/04)
Page: 6 of 6