197407189-10-7-2021-30-CC-DLOE-C7KQ5F-20211007115152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197407189
Report Date: 10/07/2021
Date Signed: 10/07/2021 12:15:45 PM

Document Has Been Signed on 10/07/2021 12:15 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:	GRAY FAMILY CHILD CARE		FACILITY NUMBER:	197407189
ADMINISTRATOR:	GRAY SHELLY LYNN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 892-0688
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 12	DATE:	10/07/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Shelly Gray		TIME COMPLETED:	12:00 PM

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On 10/07/2021 at 8:30 am Licensing Program Analysts (LPAs), Deborah Lowe and Carolyn Tuba conducted an unannounced Annual Required Inspection and was met by Licensee, Shelly Gray. Also present was/were Staff #1 (S1). Days and hours of operation are Monday – Friday 7:00 am – 5:45 pm.

LPAs toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the kitchen, bathroom, children’s play room and living room are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of locked doors. Swimming pool is fenced per regulation. The pool gate is self-latching, self-closing and opens away from the swimming pool. No windows or doors have direct access to the pool area. 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.

There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818) 892-0688.

There are currently 2 infants in care. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Deborah Lowe
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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: GRAY FAMILY CHILD CARE	FACILITY NUMBER: 197407189
	VISIT DATE: 10/07/2021

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completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children, no car seats observed at facility. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPAs reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 2/18/2020. Licensee’s pediatric CPR/First Aid expires on 6/14/2022. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

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.

Criminal Record Statement Family Child Care Homes

Licensee, Shelly 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.

Incidental Medical Service (IMS) is not being provided.

Incidental Medical Services (IMS) policy

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

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Deborah Lowe
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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: GRAY FAMILY CHILD CARE	FACILITY NUMBER: 197407189
	VISIT DATE: 10/07/2021

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Safe Sleep

LPA discussed the safe sleep regulations with licensee, Shelly 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.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following technical advisories were provided: 102369(b)(9) and Health & Safety Code 1596.8662(b)(1) Licensee was provided a copy of appeal rights.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Deborah Lowe
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

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