197415142-9-29-2023-30-CC-JLAO-CW62VF-20230929174352

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197415142
Report Date: 09/29/2023
Date Signed: 09/29/2023 05:45:37 PM

Document Has Been Signed on 09/29/2023 05:45 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	KSIESKI FAMILY CHILD CARE		FACILITY NUMBER:	197415142
ADMINISTRATOR:	KSIESKI, CAROLINE A.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(424) 227-9146
CITY:	WESTCHESTER	STATE: CA	ZIP CODE:	90045
CAPACITY:	12	CENSUS: 11	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Caroline Ksieski		TIME COMPLETED:	12:20 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 9/29/2023 Program Analysts (LPA), Judy Laureano and Cristina Castellanos conducted an unannounced Annual Required Inspection at 5541 W. 76th Street, Westchester, CA 90045. During today’s inspection was licensee Caroline Ksiekski and two other adults; S. Ruelas and A. Aguirre. The hours of operation are Monday through Friday 8:00 am to 5:00 pm. LPAs toured the home inside and outside and reviewed facility sketch. Currently facility is available to take children ages 18 months to 5 years old. Currently. Facility is licensed for a Large Family Child Care license with a max capacity of 12 children. Licensee is not available for evening, overnight care or weekend care. Currently living in the home is licensee, licensee’s husband, C. Ksiekski, and 2 minor children. This is a single family home with 3 bedrooms, 2 ½ bathroom with living room/dining room area, kitchen and playroom. Child care is conducted in the playroom. Per licensee, living room is used for napping. Bathroom that children use is located outside the playroom; ½ bath was observed and inspected. Licensee confirmed that children eat in the play room. Licensee confirmed the following areas as OFF LIMITS: bedroom 1-3, bathroom 2, dining room and kitchen area. Kitchen area and dining room area is used as a walkway to access the living room area for nap time. Parent do not use the main entrance of the home, families enter the home through the side gate, entering directly to the playroom. LPAs reminded licensees that any area designated as OFF LIMITS should be made inaccessible during the hours of operation and/or while children are present. The backyard is used for outdoor space. LPAs observed age appropriate toys. LPAs observed a wooden play structured with wood chips providing a soft cushioning. to the children in care.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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

Document Has Been Signed on 09/29/2023 05:45 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: 09/29/2023

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
1 2 3 4	Based on interview &record review, the licensee did not comply with the section cited above in 3 out of 3 expired certification which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee agreed to complete training and provide proof of completion to LPA via email by due date. www.madatedreporterca.com

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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: KSIESKI FAMILY CHILD CARE	FACILITY NUMBER: 197415142
	VISIT DATE: 09/29/2023

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
26
27
28
29
30
31
32

Page 2
There are no firearms or ammunition on the premises. Detergents, cleaning compounds are kept in the bottom of the kitchen cabinet- locked with a safety latch and also stored in the top shelf of the playroom’s closet.

Home does not have any children enrolled that need medication. Licensee confirmed that home is available to take in a child that might need medication and is aware that medication needs to be in its orignal content with current prescribition.

LPAs observed licensee test the carbon monoxide and smoke detector in the home. LPAs observed a working fire extinguisher in the day care space/playroom. Licensee confirmed that home provides meals and snacks. LPA discussed the importance of maintaining a system where allergies and food restrictions are noted. Licensee confirmed that home is currently participating with a local food program.

Adequate heating and ventilation for safety and comfort were observed in the space. Safe toys and play equipment were observed. The home has working telephone service and
LPAs confirmed the phone numbers 310-295-2499.

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.
Capacity as specified on the license is being maintained during today’s inspection. LPAs observed 11 children present during today’s inspection.

Licensee’s Pediatric CPR and Pediatric First Aid was taken on 2/17/2022. Licensee’s Preventative Health and Safety Training was taken on 2/20/2022. LPAs observed all staff files to have current Pediatric CPR and Pediatric First Aid. Mandated Reporter training was not current, LPAs issued a Type B citation for expired Mandated Reporter Training certification. LPAs reminded licensee the importance of making sure all vendors providing Pediatric CPR and Pediatric First Aid need to be EMSA approved. LPAs discussed all necessary forms needed in each staff file and children’s file. LPA provided licensees with a current copy of the LIC 311D to use as a reference when auditing files.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

Page: 4 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: KSIESKI FAMILY CHILD CARE	FACILITY NUMBER: 197415142
	VISIT DATE: 09/29/2023

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
26
27
28
29
30
31
32

Page 3
LPAs reviewed 6 children’s files and observed files to be complete.
To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Family Child Care Homes Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPAs 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-andresources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.
Licensee, Caroline Ks, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Caroline Ksieski,.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5