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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415142
Report Date: 02/03/2022
Date Signed: 03/24/2022 02:26:47 PM


Document Has Been Signed on 03/24/2022 02:26 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/23/2022 03:49 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

NARRATIVE
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Licensing Program Analyst, (LPA), Deborah Lowe is delivering an amended report of an annual required inspection by LPA Rios. On February 3rd, 2022, Licensing Program Analyst Lisa Rios went to the Ksieski Family Child Care to conduct a 1 year annual required inspection. There are 9 children in care ages 2 years - 5 years old. The home operates Monday-Friday 8:00am to 5:00pm.

Upon entry to the home, there are four children listening to a story as they sit in chairs while another five take a nap. Most required postings are in a prominent area are posted, licensee is aware that the PUB269, child safety restraints needs posting. LPA Rios directed the licensee to LIC311D that lists required documents to be posted and stated to licensee that it needed to be located where the parents could see it.
Care for children takes place in the living room and family. There are glass doors blocking this area off from the kitchen and other areas of the home. There are toys and activities for all ages of children served. There is a bathroom that has child proof locks on all drawers and cabinets and a child's potty seat attachment on the toilet for children's who are being potty trained. There is a required fire extinguisher in the classroom that requires service (last service 11/17/2020) and a complete first aid kit in the bathroom. Outdoor area is in back of the house and was inspected for safety.

Licensee is being issued 2 type A citations, 4 type B citations today and a technical violation for missing records and documentation.

LPA Rios conducted a record review in Guardian, that showed the licensee had an employee who had not had a criminal record clearance prior to working in the facility which poses an immediate health, safety or personal rights risk to persons in care. This Type A citation will include a civil penalty of $200, $100 for each day the employee was present without a clearance.

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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 02/03/2022 04:38 PM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: KSIESKI FAMILY CHILD CARE
FACILITY NUMBER: 197415142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obesevation both bleach andf lysol were left out on the diaper changing table which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2022
Plan of Correction
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Staff immediately removed the lysol and bleach and the licensee put in a closet high on a shelf.
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a record review in Guardian, the licensee had an employee who had not had a criminal record clearance prior to working in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2022
Plan of Correction
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Licensee asked the employee to leave immediately and will make sure that she is cleared through livescan prior to working in the facility.

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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2022 04:38 PM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: KSIESKI FAMILY CHILD CARE
FACILITY NUMBER: 197415142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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Licensee will email LPA Rios at lisa.rios@dss.ca.gov the mandated reporter training.
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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Licensee will email LPA Rios at lisa.rios@dss.ca.gov the Employee Rights.

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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2022 04:38 PM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: KSIESKI FAMILY CHILD CARE
FACILITY NUMBER: 197415142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(11)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (11) A signed statement regarding their criminal record history as required by Section 102370(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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Licensee will email LPA Rios at lisa.rios@dss.ca.gov the criminal record history statements.
Type B
Section Cited
CCR
102416.1(a)(6)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (6) Documentation of completion of training on preventative health practices as required by Section 102416(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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Licensee will email LPA Rios at lisa.rios@dss.ca.gov the completion of Health Course plus 1 hour nutrition.

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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KSIESKI FAMILY CHILD CARE
FACILITY NUMBER: 197415142
VISIT DATE: 02/03/2022
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee 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 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.

LPA discussed the safe sleep regulations with licensee 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 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.

A notice of site visit was given and must remain posted for 30 days. LIC9224 was given to licensee and reminded to have each parent sign and keep in children's files for 12 months.

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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