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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191805066
Report Date: 07/29/2022
Date Signed: 07/29/2022 01:11:32 PM


Document Has Been Signed on 07/29/2022 01:11 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 CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:CLARK FAMILY CHILD CAREFACILITY NUMBER:
191805066
ADMINISTRATOR:CLARK, ROZLYN R.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 756-7820
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY:14CENSUS: 5DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sandy Lopez, AssistantTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Alicia Mooberry conducted a Required Annual Inspection on this date. LPA met with Sandy Lopez, Assistant. Licensee was not present upon arrival and arrived at TIME. Licensee was reminded that Licensee was not present in the home during inspection. Licensee not present in the home during the hours of operation. Per phone call licensee, they are at a dentist appointment. The licensee was reminded that When circumstances require the licensee to be temporarily absent from the home, absences shall not exceed 20 percent of the hours that the facility is providing care per day. LPA provided the inspection Entrance Checklist, LIC 126 and Assistant and toured the facility. There were 5 children present including 1 infant. Also present was 16 year old assistant. Per Assistant the hours of operation are Monday-Friday 6:30am-6:00pm. All Adults present have been cleared and associated to the facility.

This is a one story home with 3 bedrooms and 1 bathroom.


Areas Accessible to children in care: Living room, den (main daycare area), dining room, kitchen and back yard.
Off limit areas: Three (3) bedrooms, back house and storage room attached to the back house.
Childcare children use the only bathroom located in the hallway next to the kitchen.
Areas that are inaccessible to children in care were observe to be closed and locked.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:


Fireplace in the childcare area observed to be not screened, this poses a potential risk to the health and safety of children in care.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged the service tag indicated last Service date 5/13/22, Assistant was reminded that fire extinguisher needs to be serviced yearly.

Page 1 – Report Continues

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CLARK FAMILY CHILD CARE
FACILITY NUMBER: 191805066
VISIT DATE: 07/29/2022
NARRATIVE
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The home maintains telephone service via cell phone. The home is observed to be clean and orderly. There are toys and other age appropriate material available for children. LPA observed that detergents, cleaning compounds are in the kitchen inaccessible to children by safety lock. Assistant states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in living room, away from the other children. Per Assistant they are not aware of any firearms or weapons stored in the home.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, and documentation of 15-minute Infant Sleep Check (0-24 months)


Child #1, age 18 months is missing Infant sleep log.

Staff records were not available for review. Assistant provided proof of approved Pediatric First Aid and CPR certification.

Parents drop of children through the side gate. LPA observed required posted documentation in facility, however not posted in a publicly accessible area. LPA provided Assistant with updated Publication (PUB) 394- Notification of Parent Rights with the current Licensing Office information. LPA reminded staff to place the Facility License, PUB 394, Licensing Form (LIC) 9148- Earthquake Preparedness form where visible to parents.


The LIC 9040- Facility Roster was not available for review, which poses a potential risk to the safety of children in care.

Infant Care: The facility cares for infants. LPA informed staff of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP and LIC 9227. LPA observed a playpen available for the infant in care.

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.

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SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
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: CLARK FAMILY CHILD CARE
FACILITY NUMBER: 191805066
VISIT DATE: 07/29/2022
NARRATIVE
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Currently, children are using the back yard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has a wooden play structure with swings, secured to the ground, no chipping or wood splinters were observed. LPA reminded staff to follow manufacturer age recommendations. The ground is made of natural grass and is cushioned. Assistant stated children are supervised at all times while they play. There toys and other age appropriate materials available. LPA did not observe any objects that could be hazardous to children in care.

LPA reminded staff to visit the Los Angeles Public Health Department LAPDH.gov for the latest COVID-19 guidance and recommendations.

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

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.

Assistant and Licensee were reminded that all adults 18 and over living or working in the home, 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.

Based on the LPA's observations and records review the following deficiencies will be cited today in accordance with California Title 22 Regulations.

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

Exit interview conducted and report was reviewed with the Sandy Lopez, Assistant

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/29/2022 01:11 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CLARK FAMILY CHILD CARE
FACILITY NUMBER: 191805066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022

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
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Based on observation, the licensee did not comply with the section cited above due to a wood burning fireplace in the main daycare area is not screened and is accessible to children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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The licensee will screen fireplace and make it inaccessible to children in care, a photo of correction will be sent to LPA via email by POC due date
Type B
Section Cited
CCR
102416.1(d)
Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff present did not have a facility file available for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Per licensee, a copy of the requred faciltiy forms (LIC 126) will be sent to LPA via email by POC due date.

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 CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 07/29/2022 01:11 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CLARK FAMILY CHILD CARE
FACILITY NUMBER: 191805066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to the facility roster was not available for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Per licensee, the LIC 9040, Facility Roster will be completd and sent to LPA by email by POC due date
Section Cited
Infant Safe Sleep
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
LIC809 (FAS) - (06/04)
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