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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414463
Report Date: 02/14/2020
Date Signed: 02/14/2020 05:21:55 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:ROA FAMILY CHILD CAREFACILITY NUMBER:
197414463
ADMINISTRATOR:ROA, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 219-1677
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:14CENSUS: 8DATE:
02/14/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Carmen RoaTIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA), Keyona Scott, conducted an unannounced Annual 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, Carmen Roa on 02/14/2020. Licensee and three children, which includes two infants, were present during the inspection. Upon LPA's arrival to the home, LPA observed a parent feeding an infant child. Shortly after LPA's arrival, the second parent arrived to the facility. LPA then became aware the parents were there to pick up the infant child. All Adults 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 2:35 PM.

Licensee's son (Adult 1), arrived at the home at approximately 3:25 PM. Licensee's Assistant (Adult 2), arrived at the home with five school age children at approximately 3:35 PM.

The home is a one story, four bedroom, two bathroom home with a living room, dining room, 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 three bedrooms located to the rear of the home. The three bedrooms are made inaccessible by closed doors during operation hours. The primary child care area for the younger children in care is in the living room and dining room of the home. The school age children utilize the den as the primary child care area. The children utilize the bathroom located in the den of the home. The children also utilize the bedroom located at the rear of the hallway for napping. LPA observed napping mats in the bedroom. LPA observed safety locks on the cabinets and drawers in the kitchen.

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 ceiling fans as a cooling source and wall heater as a heating 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 pet dogs and birds at the home. The pet birds are caged and located in the patio area outside of the den. The pet dogs are inaccessible to the children in care. Page 1

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

DATE: 02/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2020
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 5
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: ROA FAMILY CHILD CARE
FACILITY NUMBER: 197414463
VISIT DATE: 02/14/2020
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 dual working smoke and carbon monoxide detector. There is also a first aid kit equipped in the home. Licensee was unable to provide First Aid and CPR card for Licensee or Assistant. Per review of inspection conducted in 2018, Licensee's First Aid and CPR expired 03/2019. Per interview with Licensee and Assistant, does not recall renewal of First Aid/CPR in 2019. Licensee does not have current First Aid and CPR Certification; this poses a potential risk to the health, safety and/or personal rights risk to the children in care. Licensee also completed Mandated Reporter training on 07/18/2018. LPA observed required postings posted.

Toys and playthings are safe, orderly and age-appropriate for the children. 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 patio area outside of the den. The outdoor play area is fully fenced in and also is free from defects or dangerous conditions. LPA observed a separate gated yard area (off-limits) separate from where the children play. LPA observed a gated pond area in the off-limit yard area.

LPA observed current Child Care Facility Roster of the children enrolled. There are currently eleven children enrolled at the facility.

The facility operation hours are Monday through Friday, 6 AM to 6 PM.

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

DATE: 02/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2020
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: ROA FAMILY CHILD CARE
FACILITY NUMBER: 197414463
VISIT DATE: 02/14/2020
NARRATIVE
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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 General and Child Care Mandated Reporter 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/.

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.


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

DATE: 02/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2020
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: ROA FAMILY CHILD CARE
FACILITY NUMBER: 197414463
VISIT DATE: 02/14/2020
NARRATIVE
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Licensee was provided the following form during the inspection:
PUB 394: Notification of Parents' Rights

LPA advised Licensee, the following forms/brochures will be mailed to Licensee:
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 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.

The facility was not operating in substantial compliance during this inspection on 02/14/2020. The facility was cited for Title 22 deficiency 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 (LIC 9102-TV) along with appeal rights were given to Licensee, Carmen Roa and Assistant, 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: 02/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2020
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: ROA FAMILY CHILD CARE
FACILITY NUMBER: 197414463
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2020
Section Cited

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102416 Personnel Requirements
(c) 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 is not met as evidenced by:
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Based on observation, record review and interview, Licensee does not have current First Aid and CPR certification, which poses a potential Health, Safety and Personal Rights risk to the children in care.
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Licensee states once training is completed, will scan or fax a copy of the CPR/First Aid Certificate to LPA.

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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: 02/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2020
LIC809 (FAS) - (06/04)
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