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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197403941
Report Date: 12/18/2019
Date Signed: 12/18/2019 03:08:47 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:POLAND FAMILY DAY CAREFACILITY NUMBER:
197403941
ADMINISTRATOR:POLAND, VICTORIA D.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 841-8467
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:14CENSUS: 7DATE:
12/18/2019
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Victoria Poland-LicenseeTIME COMPLETED:
03:30 PM
NARRATIVE
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On 12/18/19 at 12:15pm, Licensing Program Analyst (LPA) Adrian Risher conducted a 3 Year Required visit. LPA provided Licensee with the purpose of the visit and was granted access to the facility. LPA met with Victoria Poland, Licensee. LPA toured the inside and outside of the property at 12:20 PM with the Licensee. LPA observed the home to be clean, safe, orderly and well ventilated. There were 7 children present at the time of inspection with 1 assistant. The operating hours are Monday thru Friday 24 hours.

LPA observed the single-story home to have a Living Room, Dining Room, Kitchen, 3 bedrooms, and 2 bathrooms. The home has a detached garage. The Licensee utilizes the living room, one bathroom and the detached garage as the day-care. The rest of the home is inaccessible to the children. The living room is used for napping. The children use mats in the living room when they are napping. The children use the bathroom located towards the back of the home right off of the kitchen. The garage is used for daily activities. The children use age-appropriate tables and chairs in the backyard for eating. The parents enter the home from the side gate or the front entrance.

LPA observed age appropriate toys and equipment for the children. Licensee states that there are no weapons in the home. Licensee reports that there are no pets in the home. The kitchen and bathroom areas were inspected for proper storage of chemicals, detergents, cleaning compounds, medications and sharp pointed objects. All items were made inaccessible to children. Kitchen cabinets were made inaccessible to children in care with locks. LPA observed All electrical outlets with protective covers. page 1

SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Adrian RisherTELEPHONE: (424) 301-3050
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
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 6
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: POLAND FAMILY DAY CARE
FACILITY NUMBER: 197403941
VISIT DATE: 12/18/2019
NARRATIVE
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LPA observed operable smoke detectors and carbon monoxide detectors throughout the home which were tested during inspection. The home is equipped with 1 (2-A:10-B:C) Fire Extinguisher and First Aid kit which includes tweezers, thermometer, and band aids. Licensee CPR card expires (Feb 2020) and the assistant's CPR card expires Mar 2020. The fireplace is properly screened and is inaccessible to the children. Licensee stated that she uses fans when the weather is hot. Licensee stated that heaters are used when needed.

LPA inspected the outside area and observed age appropriate toys. There are no bodies of water at the home. LPA observed a playhouse, toys,appropriate equipment and chairs with tables. The outside playarea is gated.


The licensee and assistant have required immunizations. Licensee has not completed Mandated Child Abuse Reporter Training. Staff files were reviewed during inspection as well. LPA reviewed records related to earthquake drills and fire drills which were found to be current. All required Child Care Postings was observed on the Parent Board during inspection. Children's files were inventoried and reviewed at the time of inspection. Children files were completed.

Items to be provided to LPA: 1. Mandated Reporter Certificate 2. Preventative Health & Safety Certificate

2 deficiencies cited

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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Adrian RisherTELEPHONE: (424) 301-3050
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: POLAND FAMILY DAY CARE
FACILITY NUMBER: 197403941
VISIT DATE: 12/18/2019
NARRATIVE
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In accordance with California Code of Regulations, Title 22, Division 12, Chapter 3 of Family Child Care Homes, during today's visit, 2 deficiencies were observed. (Please see LIC 809D for deficiencies cited.) Please see LIC 811 Confidential Names List.

Exit interview was conducted and a copy of report was provided. Appeal rights were provided and discussed.

The following was discussed with the licensee:


No smoking is allowed on a day care premises. Only children eating may be in high chairs. Provider is required to wash hands after every diaper change. LPA did not observe any baby walkers, exersaucers or bouncers.
MANDATED REPORTER: LPA also explained Assembly Bill 1207 California Child Care Workers; Mandated Training Requirement. Beginning January 1, 2018, all licensed providers, applicants, directors and employees must complete Mandated Reported Training prior to March 30, 2018 and renew training every two years at: www.mandatedreporterca.com.

Immunization records are to be obtained from parents prior to a child being left with provider. Immunization records shall be kept on blue cards from the local health department. Title 22 Regulations, Child Care Quarterly Updates viewed at www.ccld.ca.gov.

LPA informed licensee of regulations regarding reporting unusual incidents and injuries within 24 hours and submit an incident report to the department within 7 days.

The licensee was reminded that all adults 18 and over living or working in the home and visiting on a frequent basis must be fingerprint cleared prior to being on the premises. A civil penalty will be assessed if this regulation is violated. page 3

SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Adrian RisherTELEPHONE: (424) 301-3050
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: POLAND FAMILY DAY CARE
FACILITY NUMBER: 197403941
VISIT DATE: 12/18/2019
NARRATIVE
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Senate Bill 792: this bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles.

New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

Nutrition Requirement: Beginning January 1, 2016, AB 290 will require for each new license issued, at least one director or teacher at each child care center or family child care home to have at least one hour of training in the importance of childhood nutrition. This applies to anyone submitting a new application, relocating their facility, selling their facility or transferring their license. Please note this training cannot be completed online or by home study programs. The training must be taken from an Emergency Medical Services Authority (EMSA) approved training program OR an accredited college or university.

Licensee/Applicant was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and to never shake a baby to prevent the Shaken Baby Syndrome. A handout regarding Safe Sleep was provided.


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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Adrian RisherTELEPHONE: (424) 301-3050
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: POLAND FAMILY DAY CARE
FACILITY NUMBER: 197403941
VISIT DATE: 12/18/2019
NARRATIVE
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Update on Incidental Medical Services: Facilities that provide Incidental Medical Services (IMS) must identify those services in their facility’s Plan of Operation and submit an updated Plan of Operation to the Department. Incidental Medical Services Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering EpiPen Jr. and EpiPen or other Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Emptying an Ileostomy Bag.

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment. page 5

SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Adrian RisherTELEPHONE: (424) 301-3050
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: POLAND FAMILY DAY CARE
FACILITY NUMBER: 197403941
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2020
Section Cited

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1596.8662 ...training for mandated reporter...
... a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training ...
This requirement was not met as evidenced by:
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Licensee did not provide proof of completion of the mandated reporter training. This poses a potential risk to the health & safety to the children in care.
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Type B
01/17/2020
Section Cited

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1596.866 Additional health and safety training; condition of licensure
A preventive health practices course or coursesthat include instruction in the recognition, management, and prevention of infectious diseases,....
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This requirement was not met as evidenced by:
Licensee was not able to provide proof of completion of preventative health & safety course. This poses a potenital health & safety risk to the children in care.
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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: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Adrian RisherTELEPHONE: (424) 301-3050
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2019
LIC809 (FAS) - (06/04)
Page: 6 of 6