197407526-6-10-2022-54-CC-AMOY-CF9SJT-20220610135539

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197407526
Report Date: 06/10/2022
Date Signed: 06/10/2022 01:56:04 PM

Document Has Been Signed on 06/10/2022 01:56 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	WILLIAMS FAMILY CHILD CARE		FACILITY NUMBER:	197407526
ADMINISTRATOR:	WILLIAMS, DEBRA D.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 321-3940
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90062
CAPACITY:	14	CENSUS: 5	DATE:	06/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Debra Williams, Licensee		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Alicia Mooberry conducted a Required Annual Inspection on this date. LPA met with Debra Williams, Licensee. LPA explained the purpose of the inspection and provided Entrance Checklist, LIC 126. Licensee provided tour of facility. LPA inspected rooms/areas on the facility sketch both off limits and in which child-care services are provided and to which children have access. Per licensee the hours of operation are Monday-Friday 24 hours. Licensee understands that care of children cannot exceed 24hours. There were 5 children present. Also present was Ronald Woods, cleared adult.

This is a single story, 3 bedroom/2 bath home. The main childcare areas are the living room and two (2) bedrooms. Other areas accessible to children are: Kitchen and backyard.

Off limit areas, per Licensee and facility sketch are: Bedroom to the front of the home, two (2) separated storage units located in the backyard. The bedroom and storage units are maintained closed and locked while children are in care.

LPA reminded licensee of required documentation to be posted in facility entrance including: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA observed completed facility records including; LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan. LPA provided PUB 394 with updated Regional office information.

At 9:30am LPA observed chemicals and cleaning agents in the unlocked cabinet in bathroom (located in hallway by living room) accessible to children in care (photo taken), this poses an immediate risk to the health and safety of children in care.

At 9:37am while touring the backyard, children's play area, LPA observed a barbecue grill, wood burning fire pit (with wood inside), a 6 inch board with metal spikes and metal cabinet with sharp edges (photo taken) posing an immediate risk to the health and safety of children in care. Per licensee the children will be taken to the park for outdoor playtime until backyard is cleared of hazardous items. ----------Page 1 – Report Continues

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia Mooberry	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 197407526
	VISIT DATE: 06/10/2022

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The children have access to use both bathrooms in the home. Bathroom 1 is located in hallway off living room. Bathroom 2 is located towards the back by the kitchen and observed to be clean and free of hazards.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged and was purchased on 06/2022 , Licensee was reminded that fire extinguisher needs to be serviced yearly. The home maintains telephone service via cell phone. Age appropriate toys and material available for children. LPA observed that detergents, cleaning compounds are in the kitchen inaccessible to children in overhead cabinets and under sink cabinets with safety locks. Licensee was advised to ensure safety locks are maintained as needed. Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in living room, away from the other children. Per Licensee there are no firearms or weapons stored in the home. There are no pets in the home.

Infant Care: Per licensee, there are no infants under 24 months currently enrolled. LPA informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP.

Currently, children are using the backyard for outdoor play. The outdoor play area was observed to be fenced. Per licensee, children are taken to the park for outdoor play regularly. Licensee stated children are supervised at all times while at the park.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, and documentation of 15-minute Infant Sleep Check (0-24 months)

Children's file review revealed Child #1 is missing facility file, Child #1-Child #5 are missing the required LIC 995A. A copy of completed LIC 857 was provided to licensee.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate.

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SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia Mooberry	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 197407526
	VISIT DATE: 06/10/2022

NARRATIVE

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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 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.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

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 observed that licensee is implementing COVID-19 precautions and procedures. Adults were wearing face masks.

Incidental Medical Services (IMS) policy was discussed. 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

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/inspection-process.

Page 3 - Report continues

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia Mooberry	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 197407526
	VISIT DATE: 06/10/2022

NARRATIVE

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LPA provided copies of updated licensing forms.

Licensee was reminded to report any unusual incident to the department within 24 hours by calling the Regional Office.

Based on the LPA's observations and records review the following deficiencies will be cited today in accordance with California Title 22 Regulations.

Deficiencies need to be cleared to protect the children’s health & safety.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.

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

Exit interview conducted and report was reviewed with the Licensee, Debra Williams. Including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia Mooberry	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/10/2022 01:56 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 197407526
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102417(g)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that there were hazardous items in the backyard where that children play which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2022
	Plan of Correction
1 2 3 4	Per licensee, the backyard willbe made inaccessible to children and the children will be taken to the park for their outdoor playtime where they will be supervised at all times, until the backyard is cleared of any hazardous items and a photo sent to LPA via email.

Type A

Section Cited

CCR

102417(g)(4)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in that cleaning product and chemicals are located in unlocked undersink cabinet in bathroom that children use which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2022
	Plan of Correction
1 2 3 4	Licensee closed off cabinet making it inaccessible to children in care. Deficiency corrected during inspection

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: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia Mooberry	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/10/2022 01:56 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 197407526
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. 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 1 out 6 children was missing the required forms which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/17/2022
	Plan of Correction
1 2 3 4	Per licensee, the application packet for child #1 will be completed and acopy sent to LPA by email by POC due date.

Section Cited

Immunizations


	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: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia Mooberry	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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