197410487-3-29-2023-12-CC-JDMO-CQE2E7-20230329171927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197410487
Report Date: 03/29/2023
Date Signed: 03/29/2023 05:20:07 PM

Document Has Been Signed on 03/29/2023 05:20 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	CHISM FAMILY CHILD CARE		FACILITY NUMBER:	197410487
ADMINISTRATOR:	CHISM, BELINDA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 951-5055
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 3	DATE:	03/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:49 PM
MET WITH:	Belinda Chism		TIME COMPLETED:	05:25 PM

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	On 03/29/2023, at 1:49 p.m., Licensing Program Analyst (LPA) Joselito L. Del Mundo conducted an unannounced annual inspection at the Chism Family Child Care Home to assess its ability to meet compliance with California Code of Regulations (CCR) Title 22, Health and Safety requirements. LPA Del Mundo met with Licensee, Belinda Chism and stated the reason for the inspection. The LPA provided copies of the LIC 126 Entrance Checklist Form, LIC 311D Forms/Records to Keep in the Family Child Care Home, and all records/forms that need to be maintain in the facility. Licensee guided the analyst on a tour of the day care areas. The day care take place in the following area of the home: den, living room, kitchen, dining room and hallway bathroom. Licensee states the day care hours of operation is 24 hours and 7 days a week. Currently living in the home is licensee and licensee's spouse. Licensee is providing transportation to children in care. During this visit, LPA observed three children present in the facility. Physical Plant The facility is a two story house. LPA advised licensee to keep the home clean and orderly. The facility has heating and ventilation for safety and comfort, maintains a telephone service, (Licensee was advised that the cell phone shall be charged and available during day care hours) has safe age-appropriate toys, play equipment and materials for children in care to use. Licensee has 2 mats and 4 sleeping bags available for napping children. At the time of this inspection, there are no fixtures, furniture, and equipment that have been banned or recalled by the United States Consumer Product Safety Commission. Per Licensee, she provides food (breakfast, lunch, 3 snacks and dinner) for children in care. LPAs 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.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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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Document Has Been Signed on 03/29/2023 05:20 PM - It Cannot Be Edited

Created By: Joselito DelMundo On 03/29/2023 at 04:24 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: CHISM FAMILY CHILD CARE	FACILITY NUMBER: 197410487
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102421(b)

Child's Records

(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not maintain a copy of LIC 700 Identification and Emergency Medical Information for child #1 and did not comply with the section cited above which posed a potential Health, Safety or Personal Rights risk to persons in care.
	POC Due Date: 04/12/2023
	Plan of Correction
1 2 3 4	Licensee will email a copy of LIC 700 Identification and Emergency Medical Information of child #1 to LPA.

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 maintain a copy of LIC 627 Consent for Emergency Medical Treatment for child #1 and did not comply with the section cited above which posed a potential Health, Safety or Personal Rights risk to persons in care.
	POC Due Date: 04/12/2023
	Plan of Correction
1 2 3 4	Licensee will email a copy of LIC 627 Consent for Emergency Medical Treatment of child #1 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:

Lady King

LICENSING EVALUATOR NAME:

Joselito DelMundo

LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: CHISM FAMILY CHILD CARE	FACILITY NUMBER: 197410487
	VISIT DATE: 03/29/2023

NARRATIVE

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The home is free from defects or conditions which might endanger a child. The is fireplace is covered with a metal fence and is located in the den of the facility. It has operational carbon monoxide, smoke detector and fire extinguisher which meet established standards and the last service date was on 08/25/2022. Detergents are stored in the laundry room (off limits). Cleaning compounds are stored under the kitchen sink where they are locked and inaccessible to children. Medicines are stored in the upper cabinets of the kitchen. Licensee has two first aid kit boxes stored in the hall closet by the hallway bathroom. Per licensee, there are no firearms in the facility. Licensee is advised that all children, age and ability permitting, and the provider, the assistant provider (if any), and other members of the household, have been instructed in their duties under the disaster plan. Newly enrolled children are informed promptly of their duties as required in the emergency plan. Fire drills and disaster drills are conducted (dated 03/29/2023) once every six months, the licensee document the drills, including the date and time of each drill. There are no baby walkers in the facility. Licensee is aware that smoking is prohibited on the premises of a family child care home. Per licensee, she has three dogs which are inside the dog kennel and is planning to put additional cover on the metal fence to prevent access to children

Currently, there are 6 children enrolled in their program. For infants enrolled, licensee is aware that there must be one crib or play yard for each infant who is unable to climb out of the crib or play yard. The crib(s) or play yards use by the facility must meet the United States Consumer Product Safety Commission safety standards. Placement of crib(s or play yards shall not hinder entrance or exit to and from the space where infants sleep. Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged. The mattresses shall be made specifically for the size crib or play yard in which they are placed.

The facility has no body of water on the premises. The outdoor play area is properly fenced and supervised by the licensee. Per licensee, the patio posts of the outdoor play area are currently under

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: CHISM FAMILY CHILD CARE	FACILITY NUMBER: 197410487
	VISIT DATE: 03/29/2023

NARRATIVE

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renovation. The LPA also explained to Licensee how to obtain information from the Community Care Licensing (CCL) website (www.cdss.ca.gov).

Care and Supervision

Per Licensee, she is present in the home during child care time and ensure all children in care are supervised at all times. When circumstances requires her to be temporarily absent from the home, she arranges for a substitute adult to care for and supervise the children during her absence. Per Licensee, her temporary absences do not exceed 20 percent of the hours that the facility is providing care per day. Licensee states that when a child shows signs of illness he/she is separated from other children in the living room.

Facility Administration
The licensee has current mandated reporter training certificate dated 01/19/2022. The Licensee has current Pediatric CPR and First Aid training certificate which expires on 09/27/2023. Licensee has proof of immunizations against influenza, pertussis and measles. Licensee has TB skin test on file. Licensee was advise to take the preventive health practices training that includes nutrition and lead poisoning. At the time of inspection, Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing on the day of the incident and/or 24 hours of incident by telephone, fax and/or in writing to the Department. Licensee is familiar with the Unusual Incident Report form, LIC624B. The report on unusual incident/injuries can also be mailed to unusualIncidentreport@dss.ca.gov

Licensee is aware that personnel records should be maintained on Licensee and each assistant (if any) and contain the following information: Licensee and staff full name; A signed and dated copy of the Notice of Employee Rights [LIC 9052]; Driver's license number if the employee is to transport children; Date of employment; Date of birth; Current home address and phone number;

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: CHISM FAMILY CHILD CARE	FACILITY NUMBER: 197410487
	VISIT DATE: 03/29/2023

NARRATIVE

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Documentation of completion of training on preventative health practices as required by Section 102416(c). Any changes to the facility from an area of the family child care home should be reported to the Department.
Records

Licensee and licensee’s spouse living in the home have received criminal record clearance.

Per Licensee, each child receiving services at the Facility are treated with dignity and respect. They are provided with safe, healthful, and comfortable accommodations, furnishings, and equipment. There is no corporal or unusual punishment of any kind, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning.

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 Facility is not in compliance per Title 22 regulations. During today's inspection, LPA Del Mundo observed deficiencies that may hinder the health and safety of the children in care. Deficiencies were cited during inspection. An exit Interview and discussion of observations were conducted with the licensee.

A copy of this Report was reviewed, Notice of Site Visit (LIC 9213) and Appeal Rights were provided to Licensee, Belinda Chism.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

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