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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192009668
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:25:22 PM


Document Has Been Signed on 12/01/2022 04:25 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:POTTS FAMILY CHILD CAREFACILITY NUMBER:
192009668
ADMINISTRATOR:POTTS, RALAINA VONETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 920-6352
CITY:INGLEWOODSTATE: CAZIP CODE:
90303 0
CAPACITY:14CENSUS: 2DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Ralaina PottsTIME COMPLETED:
04:30 PM
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 On 12/1/2022 Licensing Program Analyst (LPA), Jillinda Chandler conducted an unannounced Annual Random/ I year required visit for Potts Family Child Care Home. Present in the home was licensee Ralaina Potts and 2 infant day care children. The home is a single family, single story home, areas of day care are the living room, dining room and rear room. The home was inspected for health and safety purposes. Applicant provides overnight care and reminded that children shall be supervised at all times when awake. Licensee has two school-age children that arrived during the visit.
LPA observed the following:
Care and supervision were observed
The homes capacity was within the scope of the license
Appropriate size fire extinguisher carbon and smoke detector present & operable. LPA did not observe a carbon monoxide during todays visit
Detergents, and knives were inaccessible
The homes kitchen was inaccessible to children in care No guns or weapons present as stated by the Licensee, no weapons observed by LPA. Properly working telephone.
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Jillinda ChandlerTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: POTTS FAMILY CHILD CARE
FACILITY NUMBER: 192009668
VISIT DATE: 12/01/2022
NARRATIVE
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LPA observed the homes parent notification board; the license, facility sketch, Emergency Disaster Plan, Notification of Parent’s Rights Poster, Lead Poison Awareness, Safe Sleep and California Safety Seat Law were posted.Licensee was advised that the parent board shall be in a prominent area for review. Licensee was current in Pediatric CPR and First Aid Card
Children records available need of completion.
Immunization's records for MMR, Pertussis and Influenza were available
Licensees Mandated Reporter certificate was current
A roster was readily available and current.
Per licensee parents do not sign children in and out. LPA informed the licensee that a sign in and out sheet is required
Licensee does not provide Individual Medical Services (IMS). IMS was discussed with licensee.
All adults in the home cleared a Criminal Background Clearance.
Toys, equipment and materials available and in fair repair Children napped in play pens and cots were found to be in fair condition. Infant safe sleeping was discussed with licensee. LPA reminded licensee that children are only to use car seats during transportation, and appropriate children’s feeding chairs shall only be used during mealtime. Outdoor activities were conducted in the back yard. LPA did not observe any hazardous conditions in this area. Toys and equipment were in fair repair.
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Jillinda ChandlerTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: POTTS FAMILY CHILD CARE
FACILITY NUMBER: 192009668
VISIT DATE: 12/01/2022
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LPA shall make a return visit to inspect deficiencies and technical advisories.

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/process.

Licensee was 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.

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 [facility representative] 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.

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

Exit interview conducted and report was reviewed with the licensee Ralaina Potts

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Jillinda ChandlerTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/01/2022 04:25 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: POTTS FAMILY CHILD CARE
FACILITY NUMBER: 192009668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

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 LPA did not observe an operable carbon monoxide detector which poses potential safety risk to persons in care.
POC Due Date: 12/05/2022
Plan of Correction
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Licensee shall add carbon monoxide detectors to the home immediately, proof shall be provided no later that the POC date of 12/5/2022
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 two out of two] persons c1 and c2 did not have immunization records which poses a potential health risk to persons in care
POC Due Date: 12/05/2022
Plan of Correction
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Licensee shall obtain immunization record for C1 and C2 no later than the due date of 12/5/2022

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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Jillinda ChandlerTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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