197407408-2-28-2024-58-CC-SGAN-D2VPU5-20240228103659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197407408
Report Date: 02/28/2024
Date Signed: 02/28/2024 10:37:09 AM

Document Has Been Signed on 02/28/2024 10:37 AM - 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:	PERETZ FAMILY CHILD CARE		FACILITY NUMBER:	197407408
ADMINISTRATOR:	PERETZ, SHOSHANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 761-6309
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91607
CAPACITY:	14	CENSUS: 6	DATE:	02/28/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Shoshana Peretz, Licensee		TIME COMPLETED:	10:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Silva Garibyan conducted an unannounced annual required inspection to the above facility on 02/28/2024. LPA arrived at the facility at 07:30AM and met with Shoshana Peretz, Licensee who guided analyst on a tour of the facility. Also present was licensee's assistant (S1). LPA provided Licensee with a copy of the LIC 125 Entrance Checklist to help facilitate the inspection. Facility operation hours are Monday to Thursday from 08:00 AM 04:00PM, and Fridays from 8:00 AM to 2:00 PM. Present during today's inspection was Licensee, assistant, and six children (including 4 infants). Licensee provides services for children newborn to 5 years old. Family members residing in the home include the licensee and licensee's husband. All adults have clearances and are associated to the facility. Licensee's home is a 4 bedroom, 3 bathroom home with Living room, dining room, kitchen, recreation/activity room, and detached garage/storage. The bedroom, located at the rear right side of the home, is used for children to eat, sleep and conduct activities as needed. There is a bathroom in this room used by the children. Children have access to the detached recreation room, converted for day care activities only. The licensee is fully aware that children may not eat or sleep in the recreation room. Children eat and sleep in the bedroom. The three bedrooms, two bathrooms, Living/dining room, kitchen, and the detached garage/storage are off limits to the children in care. LPA toured all areas used by children during this inspection. Page 1

SUPERVISOR'S NAME: Betty Bell	TELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

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: PERETZ FAMILY CHILD CARE	FACILITY NUMBER: 197407408
	VISIT DATE: 02/28/2024

NARRATIVE

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Licensee reports she has no firearms or weapons in the home. The bathroom in the day care room and the kitchen was observed free of chemicals or toxic items that can pose danger to children in care. Children play in the back yard. LPA observed the yard to be clean and free of debris. The bedroom and the recreation room were observed to have age appropriate toys. Three foldable children size tables, 12 chairs, 15 cots, three play yards, and four high chairs were observed in the living room.
The licensee and assistant have completed Mandated Reporter training. LPA also observed Licensee's and assistant's current Pediatric CPR (Adult/Infant /Child) and Pediatric First Aid certifications (expire 02/2026).
The Fire Extinguishers (2A-10-BC) are mounted on the wall in the bedroom and in the recreation room. There is a working smoke and Carbon Monoxide detectors located in the kitchen. The First Aid kit was observed, and complete. The fireplace located in the living room is made inaccessible by a screen. Per Licensee, fireplace is not used.
An emergency fire/disaster drill has been completed and documented within the last 6 months.
Licensee has the following documents posted in the FCCH; Facility License (LIC 203), Notification of Parents' Rights Poster (PUB 394), Emergency Disaster Plan (LIC610a). Child Care Facility Roster (LIC9040) on file.
A review of the children's records was conducted and are found to have the following: LIC 282 Affidavit Regarding Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization Card. Licensee was unable to produce copy of safe sleep log for infant#1 #2, #3, and #4. Page 2

SUPERVISOR'S NAME: Betty Bell	TELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

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: PERETZ FAMILY CHILD CARE	FACILITY NUMBER: 197407408
	VISIT DATE: 02/28/2024

NARRATIVE

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Licensee provides meals and snacks. LPA discussed food preparation, storage and ensuring a log and information regarding dietary restrictions and allergies are kept up to date.
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.

Licensee 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.

LPA discussed the safe sleep regulations with licensee [or facility representative] 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.
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SUPERVISOR'S NAME: Betty Bell	TELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/28/2024 10:37 AM - 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: PERETZ FAMILY CHILD CARE	FACILITY NUMBER: 197407408
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in LIcensee was unable to produce copy of safe sleep log for infant#1 #2, #3, and #4 which posesa potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/06/2024
	Plan of Correction
1 2 3 4	LIcensee agreed to provide copy of the safe sleep log no later than 03/06/2024 via email to LPA Garibyan.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Betty Bell	TELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

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: PERETZ FAMILY CHILD CARE	FACILITY NUMBER: 197407408
	VISIT DATE: 02/28/2024

NARRATIVE

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LPA also informed licensee [or 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.
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/.

Licensee 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.

During the exit interview, the licensee Shoshana Peretz, confirmed that there are no Registered Sex Offenders living in the facility.

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

Exit interview conducted and report was reviewed with the licensee Shoshana Peretz

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SUPERVISOR'S NAME: Betty Bell	TELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC809 (FAS) - (06/04)

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