191608314-8-2-2022-54-CC-MAYA-CGWPB9-20220802110959

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191608314
Report Date: 08/02/2022
Date Signed: 08/02/2022 11:10:21 AM

Document Has Been Signed on 08/02/2022 11:10 AM - 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	HOLLMAN FAMILY DAY CARE		FACILITY NUMBER:	191608314
ADMINISTRATOR:	HOLLMAN, CATHERINE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 425-5030
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90713
CAPACITY:	12	CENSUS: 2	DATE:	08/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee, Catherine Hollman		TIME COMPLETED:	12:00 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	On August 2, 2022 at 9:00 am Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced inspection at the facility noted above and met with Licensee, Catherine Hollman. The purpose of the inspection was to conduct the Required - 1 Year inspection. The operating hours of the facility is Monday through Friday from 6:30 AM to 5:30 PM. Entrance Checklist (LIC 126) was provided to the Licensee upon arrival. Individuals residing in the home were discussed and noted. At the time of the inspection, 2 children were present. Per Licensee, she does not have a dual license at this address. All areas identified on the facility sketch were inspected. This facility is a single family home that consists of four (4) bedrooms, two (2) bathrooms, living room, dining room, kitchen, detached garage, fenced backyard, and fenced front yard. Areas that are accessible to children include: 1 bedroom, 1 bathroom, dining room, kitchen and fenced front yard. Per Licensee, the children utilize the fenced front yard for outdoor activity. Areas off-limits to children include: 3 bedrooms, 1 bathroom, living room, backyard and detached garage. LPA observed a child safety knob on the door inside 1 bedroom (child care area), making 3 bedrooms and 2 bathrooms inaccessible to children in care. Per Licensee, children are walked to the bathroom. LPA observed a child safety gate installed on the door frame leading into the living room, making the living room and master bedroom inaccessible to children in care. LPA also observed a child safety gate installed on the door frame in the kitchen that leads into the laundry room area and backyard. The Licensee was advised that off-limit areas must be made inaccessible during operating hours.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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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Document Has Been Signed on 08/02/2022 11:10 AM - It Cannot Be Edited

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HOLLMAN FAMILY DAY CARE	FACILITY NUMBER: 191608314
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(1)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the Licensee has the required fire extinguisher (2A10BC) that is fully charged but does not have verification of when the fire extinguisher was purchased or last serviced which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2022
	Plan of Correction
1 2 3 4	Licensee will submit to LPA via e-mail a photograph of either a receipt or verification of service date for the fire extinguisher (2A10BC or larger) by 09/02/2022.

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the Licensee did not have proof of completion for the required Mandated Reporter Training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2022
	Plan of Correction
1 2 3 4	Licensee will submit to LPA via e-mail proof of completion of the required Mandated Reporter Training (AB 1207) by 09/02/2022.

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: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/02/2022 11:10 AM - It Cannot Be Edited

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HOLLMAN FAMILY DAY CARE	FACILITY NUMBER: 191608314
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the Licensee did not have on record proof of immunization for pertussis and influenza which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2022
	Plan of Correction
1 2 3 4	Licensee will submit to LPA via e-mail their immunization record for pertussis and influenza by 09/02/2022.

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the Licensee did not have proof of completion for the required Preventative Health and Safety Practices (EMSA-approved) and current Pediatric First Aid/CPR certification (expired on 06/05/2018) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2022
	Plan of Correction
1 2 3 4	Licensee will submit to LPA via e-mail proof of completion of the Preventative Health and Safety Practices (EMSA-approved) and valid Pediatric First Aid/CPR certification (EMSA-approved) by 09/02/2022.

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: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HOLLMAN FAMILY DAY CARE	FACILITY NUMBER: 191608314
	VISIT DATE: 08/02/2022

NARRATIVE

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The following documents were posted in a prominent, publicly accessible area: Facility License, Notification of Parents' Rights (PUB 394), and Earthquake Preparedness (LIC 9148). Per Licensee, the last disaster drill and fire drill was conducted two months ago, but did not have the drills documented. LPA advised the Licensee to conduct drills every six months and document the drills, including the date and time of each drill.

Areas used by children were inspected for safety, comfort, heating, cleanliness and telephone service. LPA did not observe any wall heaters in the facility. LPA observed a fireplace located in the living room that is "off-limits" and is currently barricaded with a table. The facility has central air and heating. Detergents, cleaning compounds and medicines were made inaccessible to children in care. Per Licensee, there are no poisons kept in the home. Licensee was advised that if any poisons are purchased, it is required to be locked with a key or combination lock.

Per Licensee, there are no firearms, weapons or bodies of water on the premises. Licensee has 1 dog and a chicken coop. LPA observed the dog and chicken coop in the backyard, which is "off-limits" to children in care. LPA observed age appropriate toys and napping equipment for children. LPA observed electrical outlet covers installed in the child care area and bathroom used by children. LPA observed the required fire extinguisher (2A-10BC) that is fully charged. Licensee was advised to have the fire extinguisher serviced yearly. Smoke detector and carbon monoxide detector was tested and is operable. First Aid kit and emergency supplies are available and kept in the kitchen.

Licensee stated that she provides breakfast, morning snack, and lunch to children. Per Licensee, children do not bring food from home. Licensee was informed that if food is brought from the child's home it shall be labeled with the child’s name and properly stored or refrigerated.

LPA conducted a record review of 2 children's records and the Licensee's record. Based on the record reviews, 2 out of 2 children were missing the Affidavit Regarding Liability Insurance (LIC 282). Licensee did not have on record proof of immunization for pertussis and influenza. Licensee does not have a current Pediatric First Aid and CPR certification (expired on 06/05/2018). Licensee did not have on record the required Preventative Health and Safety Practices (EMSA-approved) and Mandated Reporter Training (AB 1207). Licensee was advised that the Mandated Reporter training (AB 1207) must be completed every 2 years and is available at www.mandatedreporterca.com.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HOLLMAN FAMILY DAY CARE	FACILITY NUMBER: 191608314
	VISIT DATE: 08/02/2022

NARRATIVE

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LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PINs), Program Quarterly Update Newsletters and other important information communication platforms.

LPA provided assistance to the Licensee on how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HOLLMAN FAMILY DAY CARE	FACILITY NUMBER: 191608314
	VISIT DATE: 08/02/2022

NARRATIVE

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To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Deficiencies were cited per Title 22 regulations (refer to deficiency pages). LPA also issued Advisory Notes - Technical Violations and Technical Assistance (LIC 9102). Appeal rights were explained and provided to the Licensee.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Licensee, Catherine Hollman.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC809 (FAS) - (06/04)

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