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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407155
Report Date: 03/28/2024
Date Signed: 03/28/2024 05:57:33 PM


Document Has Been Signed on 03/28/2024 05:57 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:GOLDSTEIN FAMILY CHILD CAREFACILITY NUMBER:
197407155
ADMINISTRATOR:ELAINE GOLDSTEINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 512-3828
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:14CENSUS: 13DATE:
03/28/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Robin Faden, AssistantTIME COMPLETED:
06:05 PM
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Licensing Program Analysts (LPAs) Elicia Calvillo and Lilia Hernandez conducted an unannounced annual required inspection to the above facility on 03/28/2024. LPAs arrived at the facility at 02:15PM, identified self and met with Robin Faden, Assistant, who guided analyst on a tour of the facility. There were 13 children present at arrival. Also present was Staff #1 (S1) and Staff #2 (S2). LPAs provided Assistant with a copy of the LIC125 Entrance Checklist to help facilitate the inspection. Facility operation hours are Monday to Friday from 7:30AM to 6:00PM.

The family child care home is a 4 bedroom, 3 bathrooms, living room, dining room, den, office and kitchen. LPA Calvillo toured the home inside and outside and a census was taken. Current facility sketch reviewed, and Assistant confirmed that two bedrooms (identified on facility map as Room #1 and Room #2), office, and one bathroom are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of safety door knobs.

LPA Calvillo observed swimming pool and a jacuzzi on the premises. LPA Calvillo observed the pool was fenced with at least five feet high fence. LPA Calvillo observed a section of the pool fence (photo taken) was on an incline and when measured it was less than five feet. The fence did not obscure the pool from view. The gate swings away from the pool and has a self-latching device located no more than six inches from the top of the gate. Per Assistant, there are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

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SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Elicia CalvilloTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GOLDSTEIN FAMILY CHILD CARE
FACILITY NUMBER: 197407155
VISIT DATE: 03/28/2024
NARRATIVE
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Assistant disclosed there is a fireplace located in the part of the house where construction is taking place. LPAs advised that once construction is over fire place must be kept inaccessible to children. There is a working fire extinguisher, smoke detector, carbon monoxide detector (child care area room #1) and adequate heating and ventilation for safety and comfort.

There are currently three infants in care. LPA Calvillo discussed Safe Sleep Regulations with licensee.

LPA Calvillo discussed the safe sleep regulations with assistant 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 assistant 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.

Assistant was reminded that children in care are to be supervised at all times and made aware that children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children.

The outdoor play area is located on the front yard of the house, is fenced and there are no hazards to children present. The backyard is off- limits to children by the use of a gate with latch inaccessible to children.

Capacity as specified on the license is being maintained.

LPAs reviewed a sample of children’s files and observed files were complete and documented on the LIC857.

An emergency fire/disaster drill has been completed and documented within the last 6 months (3/13/2024). Licensee’s Mandated Reporter Training was completed on 12/23/2021. Licensee’s pediatric CPR/First Aid expired on 01/17/2023.

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SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Elicia CalvilloTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GOLDSTEIN FAMILY CHILD CARE
FACILITY NUMBER: 197407155
VISIT DATE: 03/28/2024
NARRATIVE
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There were 3 personnel records for LPAs to review. 1 of 3 assistants was missing TB clearance.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

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/.



Assistant 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.

During the exit interview, the Assistant, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Assistant 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.

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.
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SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Elicia CalvilloTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GOLDSTEIN FAMILY CHILD CARE
FACILITY NUMBER: 197407155
VISIT DATE: 03/28/2024
NARRATIVE
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The following deficiencies listed on the attached deficiencies page are being cited in accordance with California Code of Regulations Title 22.


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

Exit interview conducted and report was reviewed with the Robin Faden, Assistant.

SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Elicia CalvilloTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/28/2024 05:57 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: GOLDSTEIN FAMILY CHILD CARE
FACILITY NUMBER: 197407155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in Assistant disclosed to LPAs that Licensee will not be present and no date is available for her return due to illness. Assistant will be supervising and providing care to children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Per Assistant, an LIC279A application with supporting documentation will be submitted to add Robin Faden, Daughter to licensee as Co-Licensee to the Department by POC due date.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

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 of 3 assistants is missing TB clearance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Per Assistant, a copy of TB clearance documentation will be submitted to LPA Calvillo 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: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Elicia CalvilloTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 03/28/2024 05:57 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: GOLDSTEIN FAMILY CHILD CARE
FACILITY NUMBER: 197407155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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 Licensee does not have current First Aid/CPR certificate on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Per Assistant, a copy of current First Aid/CPR training certificate will be submitted to LPA Calvillo via email by POC due date.
Section Cited
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: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Elicia CalvilloTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6