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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197412349
Report Date: 10/15/2019
Date Signed: 10/15/2019 03:46:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:CAMPBELL FAMILY CHILD CAREFACILITY NUMBER:
197412349
ADMINISTRATOR:CAMPBELL, RAYE M.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 756-7027
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY:14CENSUS: 4DATE:
10/15/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Raye CampbellTIME COMPLETED:
03:58 PM
NARRATIVE
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Licensing Program Analyst (LPA), Keyona Scott, conducted an unannounced Annual Random Inspection to ensure the health and safety of the Child Care Home according to Department Regulations and Health and Safety Codes. LPA met with Licensee, Raye Campbell, on 10/15/2019 at 9:19 AM. Licensee, Licensee's Assistant (Adult 1) and four children in care (includes one infant) were present during the inspection. Licensee's daughter (Adult 2), came home for lunch for a brief period during the inspection. All Adults present, residing and working in the home are fingerprint cleared and associated to the facility. LPA was guided on a tour inside and outside of the home at 9:25 AM. There are no changes to the facility layout or to the off-limit areas of the family child care home.

The home is a one story, three bedroom, three bathroom home with an open living room/dining room area, den, kitchen and attached garage. Per Licensee, no child care is conducted in the attached garage. The off-limit areas of the home are the two bedrooms located through the hallway past the bathroom to the left and the right of the home, the bathrooms located in each of the two bedrooms and the kitchen. The bedrooms are made inaccessible by closed and locked doors during operation hours. The kitchen is made inaccessible by safety gate at the entrance way near the dining room and closed door at the entrance by the hallway. The primary child care area of the home is in the den, located through the living room/dinning room area, to the rear of the home. The den was converted into a playroom for the child care children. The children also utilize the bedroom at the entrance of the hallway, to the right, as a napping area during the day and a sleeping area during the night. There is a crib and a bunk bed located in the bedroom. The children utilize the bathroom through the hallway to the left. LPA observed a screened and locked fireplace in the living room and den (playroom).

The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Home utilizes fireplace for heating and window air conditioning units and portable fans as a cooling source. Home has a working telephone. Hazardous materials in the kitchen and bathroom are inaccessible to children. According to the Licensee, there are no weapons or firearms at the home; None were observed by LPA. Per Licensee, there are no pets in the home; None were observed by LPA.
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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349
VISIT DATE: 10/15/2019
NARRATIVE
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The home is equipped with a fully charged fire extinguisher which is at least a 2A:10BC. The home is also equipped with a working carbon monoxide detector. LPA observed inoperable smoke detector in the home; this poses a potential risk to the health, safety and/or personal rights to the children in care (CCR 102417(g)(1)). There is also a first aid kit equipped in the home. LPA observed current First Aid and CPR certificates for Licensee and Licensee's Assistant with expiration dates of 10/28/2019.

Toys and playthings are plentiful and age-appropriate for the children. During the inspection, LPA observed the home to lack organization of toys and materials; this is a potential risk to the health, safety and/or personal rights to the children in care (CCR 102417(b)). Licensee agrees that no baby-walkers, bouncers, jumpers, exersaucers and similar items will be used for children in care and are kept inaccessible; None were observed by LPA.

Outside play is conducted in the backyard. The outside play area is fully fenced in. During the inspection, LPA observed tools, broom sticks, screws, chemical cans and electrical cords in the backyard play area. There were no children in the backyard at the time of the inspection. Per Licensee's Assistant, the previous evening, Licensee's Assistant was working in the backyard. Licensee and Licensee's Assistant, removed all items and made items inaccessible to children in care during the inspection. LPA advised Licensee that any such items that may pose a danger to children in care must be inaccessible to children in care during operation hours. The backyard was made free from defects and dangerous conditions during the inspection. No pools, spas, hot tubs, fish ponds, or similar bodies of waters observed during the inspection.

Per Licensee, Fire Disaster Drill log are conducted once every six months. LPA did not observe a Fire Disaster Drill log; this poses a potential risk to the health, safety and/or personal rights to the children in care (CCR 102417(g)(9)(A)(1)). LPA advised Licensee as a large Family Child Care Home, the Licensee is required to conduct Fire Disaster Drills at least once every month.

LPA did not observe current Child Care Facility Roster of the children enrolled; this poses a potential risk to the health, safety and/or personal rights to the children in care (CCR 102417(g)(8)).

The facility operation hours are Monday through Friday, 24 hours and Saturday by arrangement only.


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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349
VISIT DATE: 10/15/2019
NARRATIVE
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Licensee states is not providing IMS (Incidental Medical Services) services at this time.

Update on Incidental Medical Services: 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


Incidental Medical Services Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering EpiPen Jr. and EpiPen or other Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Emptying an Ileostomy Bag.

The following was thoroughly discussed with the licensee:


All adults living and working in the home must be fingerprinted and cleared prior to entering the facility. 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.

Licensee was reminded it is the Licensee’s responsibility to know the regulations as well as anyone who assists in providing care. Licensee was advised on how to access quarterly reports, forms, and regulations for Child Care online at www.ccld.ca.gov. Licensee was also encouraged to read the Child Care quarterly updates every season as the come out to stay informed of any changes or updates to the regulations.

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 within 24 hours of the Unusual Incident and follow up with a written Unusual Incident/Injury Report (LIC 624B) within 7 business days.



Mandated Reporter: Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/.
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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349
VISIT DATE: 10/15/2019
NARRATIVE
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Licensee informed Fire Disaster Drills are to be conducted at least once every month and log must be kept.

Licensee also informed children records and facility roster must be kept for 3 years and advised all public reports must be kept for review.

Licensee was also reminded that only children eating may be in high chairs and that car seats are utilized only for transportation.

Licensee was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome



The licensee was also recommended the following Safe Sleep Practices: always place infants on their backs for sleeping; use only a tight-fitting sheet on the crib or play yard mattress; do not hang any items from the crib or above the crib; keep all items, including blankets, out of the crib or play yard; pacifiers may be used as long as they do not have items attached to them; infants should not be swaddled or have any items covering them while sleeping; the temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold. Please note, these guidelines are recommendations for best practices only, until regulations are approved and adopted.

The licensee was advised that, once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed.


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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349
VISIT DATE: 10/15/2019
NARRATIVE
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Licensee was provided the following forms/brochures:
PIN 19-02-CCP: Safe Sleep Awareness Campaign
NIH Pub. No. 18-HD-5759: What Does A Safe Sleep Environment Look Like?
A Child Care Provider's Guide to Safe Sleep
Safe Sleep in Child Care
PUB 271: Preventing Shaken Baby Syndrome/Abusive Head Trauma
PIN 19-10-CCP U.S. Consumer Product Safety... Fisher-Price Infant Equipment Accessory Recall
PIN 19-12-CCP U.S. Cosumer Product Safety... Infant Sleeper Recall
Effects of Lead Exposure
PIN 19-09-CCLD Division Mailchimp Account Information... Subscribe For Updates
SafeBaby2indd- Safe Sleep

The facility was not operating in substantial compliance during this inspection on 10/15/2019. The facility was cited for Title 22 deficiencies during this inspection. Please see LIC 809-D of this report for further details.

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment

An exit interview was conducted, and a copy of this report (LIC 809) (LIC 809-D), Advisory Notes- Technical Violation (LIC 9102 TV), along with appeal rights were given to Licensee, Raye Campbell, whose signature confirms today's inspection and report.


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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2019
Section Cited

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102417 Operation of Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child...
(1) ... The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal.
This requirement is not met as evidenced by:
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Based on observation, LPA did not observe a working smoke detector in the home during the inspection, which poses a potential risk to the health, safety and/or personal rights to the children in care.
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Type B
10/29/2019
Section Cited

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102417 Operation of Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
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Based on observation, LPA observed the playroom to to lack organization of toys and materials, which poses a potential risk to the health, safety and personal rights of the children in care.
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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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: CAMPBELL FAMILY CHILD CARE
FACILITY NUMBER: 197412349
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2019
Section Cited

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102417 Operation of Family Child Care Home
(g) The home shall be free from defects or conditions...(9) Each family child care home shall have a written disaster plan...(A) Each... shall conduct fire drills and disaster drills...1. The licensee shall document the drills, including the date and time of each drill.
This requirement is not met as evidenced by:
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Based on interview, Licensee stated Fire Drills are conducted every six months, however, no log or record is available, which poses a potential risk to the health, safety and/or personal rights to the children in care.
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Type B
10/29/2019
Section Cited

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102417 Operation of Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child...(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
This requirement is not met as evidenced by:
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Based on observation and interview, LPA did not observe a roster of the children in care. Per interview with Licensee, was unaware of the children's roster, which poses a potential risk to the health, safety and/or personal rights of the children in care.
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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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 7 of 7