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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409552
Report Date: 11/14/2022
Date Signed: 11/14/2022 10:47:53 AM


Document Has Been Signed on 11/14/2022 10:47 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:SIMMONS FAMILY CHILD CAREFACILITY NUMBER:
197409552
ADMINISTRATOR:SIMMONS, LEFLORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 947-6375
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:14CENSUS: 3DATE:
11/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Leflora SimmonsTIME COMPLETED:
11:00 AM
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On 11/14/2022, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required 1 Year inspection at the Simmons Family Child Care. Upon arrival, the LPA met with the licensee, Leflora Simmons who guided the LPA on a tour of the facility. Family members residing in the home include two adults, (Licensee, adult daughter/college) and no children. All adults living in the home have been background cleared.
Per licensee, the hours of operation are Monday through Sunday 23 hours. Licensee's assistant (mother) was present during this inspection and 3 childcare children. (2 infants and 4 years old). Incidental Medical Services (IMS) were discussed. The licensee does not have children with IMS need at this time.

The Home is set up as follows:
This is a single story 3 bedroom, 2 bathroom home with kitchen/dining, living room, laundry room and garage. There is a community pool/spa on the premises, key required, security guard 24 hours. The home was inspected for safety, comfort, cleanliness, telephone service, central air, and heat and ventilation. The home has central heating and air conditioning. All windows have screens and are free of cracks, bugs, and debris.
· Main Area: Main day care will be provided in the living room (at entrance) and bedroom #2. Children have access to the kitchen dining area. Child Care bathroom #1 is located in the hallway. LPA observed age-appropriate toys and furniture for the children. There are games and books on the premises of this facility. · Children Bathroom (#1): Children use the bathroom down the hallway. The Bathroom was toured and inspected sink/toilet is in operable condition. Toilet and faucets are clean, safe, and operable. All poison and medications are made inaccessible to children with child safety latches on the sink cabinet and drawers. The bathroom was observed to be free and clear of hazardous items. The bathroom was clean, sanitized, and in good repair.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 11/14/2022 10:47 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: SIMMONS FAMILY CHILD CARE
FACILITY NUMBER: 197409552

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The assistant does not have shot record in the file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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The licensee will get the shot record and email to LPA.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) 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 Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The licensee does not have LIC 995 in children's file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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The licensee will ask parents to sign it and email to LPA.

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: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SIMMONS FAMILY CHILD CARE
FACILITY NUMBER: 197409552
VISIT DATE: 11/14/2022
NARRATIVE
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· Kitchen/Dining Room: The kitchen was inspected to ensure hazardous and dangerous items were inaccessible to children (Safety latches). In the kitchen, all sharp utensils, poisons, and medications are made inaccessible to children with child safety latches on cabinet doors and drawers. Sharp knives are kept in a butcher block in the gated kitchen.
· Backyard: The backyard was inspected; The backyard is gated all around. Children play in the backyard. The play area is clear and clean of debris, play area is fenced and gated all around, no body of water on the premises. There are age appropriate toys observed to be free of hazards. There is cushioning material in the play area (artificial grass). There is a gate on the right side of the yard and fenced on left side.
· Kitchen/Dining Room: The kitchen was inspected to ensure hazardous and dangerous items were inaccessible to children (Safety latches). In the kitchen, all sharp utensils, poisons, and medications are made inaccessible to children. Sharp knives are kept in a butcher block in the kitchen
Ø Off-limit: Off limit areas include Off limits area include Master Bedroom.
Ø Others:
· AC/Heating Unit / Swamp Cooler unit was observed. AC/Heating Unit is located on the right side of the home is inaccessible to children via barrels blocking access to the unit.
· Bodies of water: Per licensee, there are No bodies of water in the home. However, there is community pool in the community.
· Electrical outlets: All unused electrical outlets are plugged in and made inaccessible to children.
· Fire extinguisher (2A10BC): LPA observed there is a required fire extinguisher (2A10BC) is reading in Green and located in the kitchen inaccessible to children. It meets standards established by the State Fire Marshall.
· Fireplace: The fireplace was observed in the off-limits living room and is screened to make it inaccessible to the children with bookshelf.
· Hanging window blind cords: The cords are inaccessible to children.
· Incidental Medical Services (IMS): 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. The Licensee will not be providing IMS to the children at this time.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SIMMONS FAMILY CHILD CARE
FACILITY NUMBER: 197409552
VISIT DATE: 11/14/2022
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· Isolation area (Illness): Per licensee, if the child shows signs of illness, he/she will be separated from other children and stay in the office.
· Medications and cleaning solutions: Detergents/cleaning compounds are in upper kitchen cabinet. Medications are in the kitchen.
· Napping: Children will nap in the designated nap areas with adult supervision. LPA observed 6 mats.
· Overnight Care: Pre licensee, she does not have overnight care children at this time.
· Pets: No dog or cat.
· Phone service: There is a working landline or cell phone
· Smoke Detectors and Carbon Monoxide: The smoke detectors and carbon monoxide devices tested operable.
· The First Aid kit is located in the key-locked closet inaccessible to children. The First Aid Kit was observed complete with supplies and a first aid manual.
· Transportation: The licensee does provide transportation for children. The licensee has a valid California driver's license and valid vehicle insurance, vehicle registration.
· Weapons or Firearms: Per Licensee, there are No Firearms at the facility at this time. LPA does not observe any firearms.
Documentation:
· Child files: LPA reviewed 9 children's records, the records are incomplete and missing forms.
· CPR/First Aid: LPA observed licensee has current Pediatric CPR and First Aid Training with expiration date (7/1/23) 1 hour of nutrition training, (8) hours of Preventive Health and Safety Training.
· Criminal Record: Pre Guardian, all adults live in this facility obtain a criminal record clearance.
· Facility fees: Per Licensing Information System, facility annual fees were current.
· Fire Drill and Disaster Drill: Per the licensee, fire and disaster drills are conducted every 6 months; the last drill was documented and conducted on 10/21/2022.
· Immunization: The licensee and her assistant have the required immunizations (MMR and DTaP). The licensee and her assistant provided a written statement declining the influenza vaccination.
· Infant Sleeping Plan (LIC 9227) and Sleeping Log: There are 2 infants enroll in the facility. The licensee does not have LIC 9227 and Sleeping log in the files. LPA shared the Safe Sleeping Regulation with the licensee.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC809 (FAS) - (06/04)
Page: 15 of 18
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SIMMONS FAMILY CHILD CARE
FACILITY NUMBER: 197409552
VISIT DATE: 11/14/2022
NARRATIVE
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· Licensee has posted as required the Facility License, Emergency Disaster plan, Earthquake Preparedness and Parents Rights Poster
· Mandated Reporter Training: The licensee has completed and renewal the online mandated reporter training at www.mandatedreporterca.com on 7/14/2021
· Staff Personnel File: LPA observed 1 staff information. LPA observed Mandated Reporter Training and CPR/First Aid certificates.
· Staffing Ratio and Capacity: This is a large family childcare facility. LPA observed 3 children (1 school age and 4 preschool) during the inspection.

Ø The following information was discussed with the licensee:
ü Mandatory Forms for the children’s files and provider’s files.
ü Requirements for fire drills, earthquake drills, and documentation for both.
ü The licensee is reminded that 100% supervision is required for children at all times.
ü Capacity requirements, Roster requirements, Posting requirements, Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children’s files and provider’s files, and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. The licensee was reminded that supervision is always required for children in care.
ü Licensee was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care. Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified.
ü Licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B
ü 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).
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SIMMONS FAMILY CHILD CARE
FACILITY NUMBER: 197409552
VISIT DATE: 11/14/2022
NARRATIVE
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ü Criminal Record Statement: Licensee [or facility representative] 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 the 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.
ü Safe Sleep: 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. 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.
ü Notice of Site Visit: A notice of site visit was given and must remain posted for 30 days.
ü Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
ü Type A citation: LPA (name of analyst) informed licensee [or facility representative] (include name) that this report dated (insert visit date) document(s) (number of Type A citation) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA (name of analyst) informed the licensee [or facility representative] to provide a copy of this licensing report dated (insert visit date) that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
ü The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers, and any other items that fall into that category.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC809 (FAS) - (06/04)
Page: 17 of 18
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SIMMONS FAMILY CHILD CARE
FACILITY NUMBER: 197409552
VISIT DATE: 11/14/2022
NARRATIVE
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ü Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
n 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 sent directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

ü The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 AM - 5:00 PM.

ü A copy of the Safe Sleep Proposed Regulations was provided to Licensee.

Deficiencies cited: (See LIC 809D). The following Type B deficiencies are being cited in accordance with Title 22 of the California Code of Regulations and/or Health & Safety codes.



Exit interview conducted and the report was reviewed with the licensee Leflora Simmons.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC809 (FAS) - (06/04)
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