191222148-3-11-2022-33-CC-NTCG-CCESLR-20220311125847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222148
Report Date: 03/11/2022
Date Signed: 03/11/2022 12:59:01 PM

Document Has Been Signed on 03/11/2022 12:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	GOODMAN FAMILY DAY CARE		FACILITY NUMBER:	191222148
ADMINISTRATOR:	GOODMAN, JACQUELINE TONI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 298-5104
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	12	CENSUS: 5	DATE:	03/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:43 AM
MET WITH:	Jacqueline Goodman - Licensee		TIME COMPLETED:	01:17 PM

NARRATIVE

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Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced annual random inspection to the above facility. At 11:43am, LPA met with licensee, Jacqueline Goodman. Also present during this inspection was Licensee’s husband, who is also the assistant. The licensee states that she currently has a varying number of children enrolled. A current children’s roster is available and is current. Licensee’s hours of operation are 8am-5pm, Monday-Friday.

This is a two-story home which consists of 4 bedrooms, 4 bathrooms, kitchen, nap room, living room, den (child activity room), front yard and backyard (fenced). The children use 1 bathroom on first floor, backyard, nap room, front yard and backyard. Per licensee, areas off limits to children and parents include: second floor with 4 bedrooms and 3 bathrooms, and the downstairs living room. The licensee provides food for children in care.

The licensee states that 2 adults and 0 children currently live in the home. Licensee states that she currently has one assistant. All individuals present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in a licensed home. Per licensee, there are no weapons, firearms or bodies of water on the premises.

PHYSICAL PLANT

At 11:50am, LPA was lead on a tour of the facility by the licensee. The first area observed was the front yard. There were swings, play structures, and age appropriate toys in front. There are bushes and fencing to help keep children on the lawn. The tour continued inside towards the back kitchen. The Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are observed to be posted in the kitchen area. Next to the kitchen is the nap area where LPA observed play yards for children in care as well as sleeping equipment. At 12:00pm, a fire extinguisher was observed. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 07/12/2021, as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. REPORT CONTINUES PAGE 1 of 3

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: GOODMAN FAMILY DAY CARE	FACILITY NUMBER: 191222148
	VISIT DATE: 03/11/2022

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Next, the den was toured. Per licensee, the den is used as the main area for indoor play. There are age appropriate toys available for children to play with. Smoke and carbon monoxide detectors were tested and are operable. There are first aid supplies available. The bathroom was toured, Detergents, cleaning compounds, medications, and other items which could pose a danger are inaccessible to children in care. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock. Where children are less than five years old are in care, stairs are fenced or barricaded. There is a child safety gate which keeps stairs inaccessible to children.

At 12:07pm, LPA observed the back yard area. The outdoor play area was observed to be fenced. At this time, children are using the back yard for outdoor play time. There was another staircase that was made in accessible to children in care by means of fence. There were Cars, playhouses, slides, and age appropriate toys available for children in care.

FACILITY RECORDS:

The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 12/2023. Licensee and other personnel have completed mandated reporter training that expired on 01/08/2021. LPA discussed that Mandated reporter needs to be renewed every two years. Per Licensee, they state that during the pandemic, they forgot to renew their Mandated Reporter training and will get it done right away. A Technical Violation is being provided. The licensee does have proof of immunization against influenza, tuberculosis, pertussis, and measles. Children’s records were reviewed, including but not limited to, a copy of the emergency information card that contains all the information specified by regulation.

The following was discussed:
-Individuals who are 18 years of age or older living in the home must be finger print cleared prior to being in the presence of the children in care. Individuals within one month of their 18th birthday must be fingerprinted immediately.
-There are no pets on the premises.
-Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that falls into these categories are not permitted in a family child care facility.
-Smoking is prohibited in a license family child care home.

REPORT CONTINUES PAGE 2 of 3

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: GOODMAN FAMILY DAY CARE	FACILITY NUMBER: 191222148
	VISIT DATE: 03/11/2022

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Infant Care: Licensee states that they are currently caring for infants. LPA advised the licensee to sleep infants where they can be directly supervised at all times and advised the licensee against sleeping infants in a separate room. Licensee states that infants sleep in the nap room. LPA provided the licensee with a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics and Helping you to reduce the risk of SIDS. LPA consulted and explained Child Abuse Reporting, Updated Parent’s Rights Poster with Complaint Hotline information, Never Shake a Baby, Sudden Infant Death Syndrome (SIDS), and Safe Sleeping practices. PIN 20-24-CCP was provided and explained during the inspection.

Incidental Medical Services (IMS):

The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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.

During this inspection LPA discussed PIN 20-06 CCP, Social And Physical Distancing Guidance And Healthy Practices For Child Care Facilities In Response To The Global Coronavirus (COVID-19) Pandemic Written In Collaboration With The California Department Of Education and reviewed Child Care Covid-19 Self Assessment.

LPA advised the licensee how to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov. AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com/

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit made by a licensing representative.

Exit interview was conducted with James Goodman, Licensee's husband, at 12:55pm, but not limited to Provider Rights, Appeal Procedures, and the Agencies Consultative Role.

END OF REPORT PAGE 3 of 3

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

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