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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197413350
Report Date: 12/06/2021
Date Signed: 12/16/2021 08:11:51 AM

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:MARTINEZ FAMILY CHILD CAREFACILITY NUMBER:
197413350
ADMINISTRATOR:MARTINEZ, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 703-7367
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY:14CENSUS: 5DATE:
12/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Maria Martinez/LicenseeTIME COMPLETED:
02:45 PM
NARRATIVE
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On 12/06/2021 Licensing Program Analyst (LPA) Silva Garibyan, conducted an unannounced Required -1 Year Inspection and was met by Licensees, Maria Martinez. Days and hours of operation are M-F 7:00 a.m to 6:00p.m.

LPA toured the home inside and outside and a census was taken. Current facility sketch was reviewed. Licensee’s home is a single story, three bedroom, two bathroom home with a living room, dining room, kitchen, and backyard playground. There is a detached garage converted into a living space for renters. Licensee stated that she is currently renting her garage to occupants. LPA observed the renters to be fingerprint cleared and associated to the facility. LPA observed the off -limits bedrooms and did not observe any visible hazards. LPA also observed the off -limit bathroom, located in the front of the house, and did not observe any visible hazards. The bathroom accessible to the children was observed to be clean, safe, and did not contain toxins or hazards accessible to the children. Families and children enter the FCCH by walking through the driveway front gate, enter the living room, and walking through the kitchen into the childcare area/dining room. Children access the backyard through the Licensee's Dining area/childcare area. LPA observed gardening tools and a barbecue pit located in the licensee's backyard separate from the children's play area. LPA observed a trampoline in the backyard. The applicant is advised that trampoline is not recommended in family childcare home, if they choose to keep the trampoline and utilize it for the children in care, 100% supervision is required at all times when children are in the trampoline.

SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 3 of 11
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: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 197413350
VISIT DATE: 12/06/2021
NARRATIVE
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The trampoline does have a mesh covering all around the trampoline (with zipper). The licensee is reminded that children should never play under the trampoline.
There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. Firearms and ammunition are stored and locked separately. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. The fireplace located in the dining room is made inaccessible by a screen and will not be in use during day-care hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818) 703-7367.

There are currently three infants in care. LPA discussed Safe Sleep Regulations with licensee. There is one play yard for each infant in care. Play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks (not documented) on sleeping infants every fifteen minutes for any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is not completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping. Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC809 (FAS) - (06/04)
Page: 8 of 11
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: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 197413350
VISIT DATE: 12/06/2021
NARRATIVE
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LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensees’ Mandated Reporter Training was completed on 12/05/21. Licensees’ pediatric CPR/First Aid expires on 03/07/22. A review of records indicates that all licensee does not have immunization records on file for influenza, pertussis and measles.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.



LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.

This report shall be made available to the public upon request. Appeal Rights, LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC809 (FAS) - (06/04)
Page: 10 of 11
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: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 197413350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review,and statements made by the licensee, physical 15 minute checks were not documented which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 12/10/2021
Plan of Correction
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Licensee will document all physical checks on napping infants and provide proof to the RO by 12/10/21.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review missing proof of immunization against influenza, pertussis, and measles for licensee, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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Licensee will provide proof of immunized against influenza, pertussis, measles. Licensee will email verification of influenza, pertussis, measles to LPA Garibyan
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: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2021
LIC809 (FAS) - (06/04)
Page: 9 of 11
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: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 197413350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, an indivual infant sleep plan was never done and signed by the child's aurthorized representative, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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The licensee will have an LIC 9227 filled out for each infant (up to 12 months) in care and submit to the RO no later than 12/10/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2021
LIC809 (FAS) - (06/04)
Page: 11 of 11