191609872-10-31-2023-30-CC-JLAO-CX5VT8-20231031164244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191609872
Report Date: 10/31/2023
Date Signed: 10/31/2023 04:44:25 PM

Document Has Been Signed on 10/31/2023 04:44 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	KOELLER FAMILY DAY CARE		FACILITY NUMBER:	191609872
ADMINISTRATOR:	KOELLER, DEBRA ANN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 408-2192
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	14	CENSUS: 4	DATE:	10/31/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Debra Ann Koeller		TIME COMPLETED:	12:15 PM

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On 10/31/2023 Program Analysts (LPA), Judy Laureano and Ranita Richmond conducted an unannounced Annual Required Inspection at above mentioned facility. During today’s inspection was licensee Debra Koeller and spouse P. Koeller present.

The hours of operation are Monday through Friday 7:15 am to 5:30 pm. LPAs toured the home inside and outside and reviewed facility sketch. Currently home is available to take children ages birth to 12 1/2 years old. Home is licensed for a Large Family Child Care license with a max capacity of 14 children. Licensee is not available for evening, overnight care or weekend care. Currently living in the home is licensee and licensee’s spouse.

This is a duplex. Licensed home is the back unit that consists of 2 bedrooms and 2 bathrooms in the second floor and a bedroom/den and bathroom downstairs with a living room/dining room area, kitchen with den/playroom and back yard. Per licensee, living room and dining room area are use for eating and napping and the den/playroom is where the day care occurs. Bathroom that children use is located next to the bedroom/den.

Licensee confirmed the following areas as OFF LIMITS: the second floor which consists of 2 bedrooms and 2 bathrooms. Bedroom 1/den located in the first floor and kitchen area. LPAs observed a detached garage in the home, licensee confirmed area is OFF LIMITS and door will remain locked during hours of operations or when children are present. LPAs reminded licensees that any area designated as OFF LIMITS should be made inaccessible during the hours of operation and/or while children are present. LPAs observed the bottom of the staircase with a safety gate making the upstairs OFF LIMITS and a door knob cover on the bedroom/den door.

There are no firearms or ammunition on the premises. Detergents and cleaning compounds are kept in the bottom kitchen cabinet, magnet safety latch was observed.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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 10/31/2023 04:44 PM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KOELLER FAMILY DAY CARE	FACILITY NUMBER: 191609872
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)

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: 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 in 1 out of 1 broken fence in backyard, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/07/2023
	Plan of Correction
1 2 3 4	Licensee agrees to repair and/or replace fence outside and email proof of correction to LPA. Licensee corrected citation before the end of the inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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: KOELLER FAMILY DAY CARE	FACILITY NUMBER: 191609872
	VISIT DATE: 10/31/2023

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LPAs did not observed any open face heaters and/or fireplace in the home. Licensee confirmed that home is available to take in a child that might need medication, currently home does not have any child enrolled that needs medication. LPAs discussed the importance of making sure that all medication is current in it’s original container and all necessary LIC forms are completed.

LPAs observed licensee test the carbon monoxide and smoke detector in the home. LPAs observed a working fire extinguisher in the kitchen area. LPAs observed first aid kit in the bathroom top cabinet.

Licensee confirmed that home provides meals and snacks. LPAs discussed the importance of maintaining a system where allergies and food restrictions are noted.

Adequate heating and ventilation for safety and comfort were observed in the space. Safe toys and play equipment were observed. The home has working telephone service and LPAs confirmed the phone number 310-408-2192.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Prohibited items in Family Child Care Home flyer was provided.

Capacity as specified on the license is being maintained during today’s inspection.

Safe Sleep regulations were discussed due to program being available for infant care. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Infants up to 12 months of age are placed on their backs for sleeping. Individual Infant Sleeping Plan was discussed and LIC form was reviewed for infants currently enrolled in program.

Licensee’s Mandated Reporter training was taken on 2/20/2023 and Pediatric CPR and Pediatric First Aid was taken on 6/17/2023. LPAs reminded licensee the importance of

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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: KOELLER FAMILY DAY CARE	FACILITY NUMBER: 191609872
	VISIT DATE: 10/31/2023

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making sure all vendors providing Pediatric CPR and Pediatric First Aid need to be EMSA approved. LPAs discussed all necessary forms needed in each staff file and children’s file. LPA provided licensees with a current copy of the LIC 311D to use as a reference when auditing files. LPAs reviewed 4 children’s files and observed files to be complete.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Family Child Care Homes Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPAs 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-andresources/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 PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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: KOELLER FAMILY DAY CARE	FACILITY NUMBER: 191609872
	VISIT DATE: 10/31/2023

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Licensee, Debra Koeller, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Debra Koeller.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

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