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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409258
Report Date: 10/02/2019
Date Signed: 10/02/2019 03:57:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
197409258
ADMINISTRATOR:PEREZ, ESTHERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 264-4016
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:14CENSUS: 3DATE:
10/02/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Esther PerezTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady King-Lewis conducted an Annual Random inspection at the above facility. Upon arrival LPA was greeted by licensee, Esther Perez. LPA observed 3 children and 0 infants. LPA observed the files available for 2 children to be incomplete. Per Licensing Information System (LIS) all adults residing and working in the home have obtained background clearances. Per LIS, facility annual fees are current. The licensee is operating within proper capacity and ratios. LPA observed licensee to be present at the home and providing adequate care and supervision.

The home is comfortable and well ventilated. Licensee's poisons, detergent, cleaning compounds, medications and other items which could pose a danger to child are stored where they are inaccessible to children. LPA observed working smoke detector and Carbon Monoxide, fully charged 2A10BC fire extinguisher and working telephone. There are several age appropriate toys and a first aid kit on the premises. The day care takes place in side of house room, enclosed patio bathroom and rear yard. The backyard is completely fenced in. Licensee was informed of the risk in having a trampoline in rear yard for children play. There are no bodies of water in the FCCH. Per the licensee, there are no firearms on the premises. The licensee has current CPR and first aid that expires, 04-26-19.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2019
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258
VISIT DATE: 10/02/2019
NARRATIVE
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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

The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).

The licensee was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507

Our Quarterly updates come out every 3 months they are also now in Spanish please log in to the CCLD website or you can email our advocates to have the quarterly updates send directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258
VISIT DATE: 10/02/2019
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Licensee has the required documents posted in the FCCH; Facility License (LIC 203), Emergency Disaster Plan (LIC 610a), Notification of Parents' Rights Poster (PUB 394).

The following was discussed with the licensee;


No smoking, No infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category, earthquake safety and necessity of drills (every 6 months), required forms for children’s files, facility files, posting requirements, penalty, fingerprint clearance, and the transfer process and penalty. For additional information and forms visit our website at: www.ccld.ca.gov

Licensee is aware of CCLD child care videos on Community Care Licensing website at: https://ccld.childcarevideos.org/

Deficiencies cited in accordance to Title 22 of the California Code of Regulations and/or Health & Safety codes.

An exit Interview was conducted, a copy of this Report and a Notice of Site visit was provided to the licensee.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550

FACILITY NAME: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2019
Section Cited

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Operation of a Family Child Care Home: Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841 This requirement was not met by evidence Licensee did not provide LPA with a current copy of Child Care Facility Roster .
Type B
10/11/2019
Section Cited

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Admission Procedures and Parental and Authorized Representative's Rights; At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parents’ Rights, LIC 995A (8/06), the Caregiver Background Check
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Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05)This requirement was not met by evidence LPA did not observe Notification of Parents Rights in children's files.
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Type B
10/30/2019
Section Cited

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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 was not met by evidence LPA observed licensee CPR and first aid training has expired.
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: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4