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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191611228
Report Date: 06/07/2019
Date Signed: 06/07/2019 02:14:29 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:PALAZZOLO FAMILY DAY CAREFACILITY NUMBER:
191611228
ADMINISTRATOR:NOEMI PALAZZOLOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
3108361978
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:12CENSUS: 9DATE:
06/07/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Noemi Palazzolo, co-licensee and co-licensee's husbandTIME COMPLETED:
02:00 PM
NARRATIVE
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On 06/7/2019 at 9:45 am, Licensing Program Analyst (LPA) Denise Miranda arrived at Palazzolo Family Child Care located at 4224 Irving Place, Culver City, CA, for the purpose of verifying if the corrections were made from the previous inspection on 05/30/2019. On 5/30/2019 Licensee was over ratio.
Upon arrival LPA met the co-licensee Noemi Palazzollo and discussed the purpose of the visit. At 9:45am LPA observed the co- Licensee, co-Licensee’s husband and co-licensee’s assistant caring for a total of 9 children (6 infants and 3 preschool age children). The above mention citation has not been cleared.
LPA reviewed the children's files and observed the acknowledge of receipt of licensing reports (LIC 9224) signed by parents and placed in the children’s files.
Also, LPA observed posted The Visit (LIC 9213) – Licensee must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

During this visit, co-Licensee provided the following documents:
LIC279B Updated Children in the home,
LIC999A Updated Sketch of the house (plan and yard).
LIC855 Declaration form from co-licensee informing where licensee will provide outdoor care and supervision.

LIC279 Updated application form. LPA obtained a LIC855 declaration from licensee and co-licensee requesting to remove Licensee’s name from the license.

SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: PALAZZOLO FAMILY DAY CARE
FACILITY NUMBER: 191611228
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2019
Section Cited
HSC
102418(g)(1)
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 The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
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Co- Licensee agreed send a copy of immunization card of the children enroll on her family child care.LIcensee agrees mailed, email or fax or bring in person to LPA at El Segundo Office. no later thant 6/28/19. LPA provided a copy of Title 22 - 102418 immunization to co-licensee.
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(1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home. This is a potential risk of health and safety of the child in care. LPA reviewed nine children's files and observed that Co-LIcensee was not able to produce copy of immunization card.
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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: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
LIC809 (FAS) - (06/04)
Page: 4 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: PALAZZOLO FAMILY DAY CARE
FACILITY NUMBER: 191611228
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2019
Section Cited
CCR
102416.5(d)(1)
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102416.5 Staffing Ratio and Capacity
For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10,
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Licensee agrees to reduce the number of infants to four infants effective immediately. Licensee will submit a current Roster and schedule of each infant to CCL with the names of the children who are still enrolled at the facility. Licensee will give notices to the parents of the children who will no longer
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only if the criteria in Section 1597.465 of the Health and Safety Code are met. (1) Twelve children, no more than four of whom may be infants; This requirement is not met as evidenced by: On 6/7/19, LPA observed 6 infants and 3 preschool children age in care. This is an immediate health and safety risk.
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 attend care at the facility and submit a declaration informing the department that parecnts received the notices to CCL by 06/7/2019. Another POC visit will be conducted to verify compliance.
Co- Licensee called the parents while LPA was present to come and pick up their infants. LPA observed two infants leaving the facilty.
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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: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
LIC809 (FAS) - (06/04)
Page: 3 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PALAZZOLO FAMILY DAY CARE
FACILITY NUMBER: 191611228
VISIT DATE: 06/07/2019
NARRATIVE
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LIC855 Declaration form from co-licensee regarding outdoor care and supervision area.

LPA will be provided by mail or in person later than 6/10/2019 the following documents:
LIC610 Updated Emergency Disaster
LIC9148 Updated Checklist of preparedness.
Proof of completion of Mandated Reporter of co-licensee, Licensee's daughter, licensee;s husband and licensee’s assistant.

At the time of the plan of correction visit the facility was found not to be in substantial compliance.
· LPA observed licensee still over ratio. LPA observed six infants and three preschoolers. At 11:08am LPA observed mother of two infants arrived and picked up her two infants. LPA observed that licensee reduced her ratio to four infants.
LPA provided copy of LIC9224 Acknowledgement of Receipt of Licensing Reports.
· Licensee was not able to produce immunization card for the children’s in care.

A copy of report, a Notice of Site Visit and copy of appeal were issued and explained to the Licensee.
SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
LIC809 (FAS) - (06/04)
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