197416069-1-25-2022-12-CC-LKIG-CAMSEM-20220113124857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197416069
Report Date: 01/13/2022
Date Signed: 01/25/2022 03:14:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	COTTAGE FAMILY CHILD CARE		FACILITY NUMBER:	197416069
ADMINISTRATOR:	COTTAGE, YVONNE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 206-9049
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	14	CENSUS: 7	DATE:	01/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Yvonne Cottage		TIME COMPLETED:	12:55 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	Licensing Program Analyst (LPAs) King-Lewis conducted a required 1 year Inspection with licensee who guided analyst on a tour of the home day-care areas. The day care take place in the following area of the home: living room, family room, converted garage/day care room hallway bathroom and side and rear yard. Licensee states the day care hours of operation is less that 24 hours a days / 7 week. Currently living in the home is licensee, licensee's spouse and minor daughter (15). Physical Plant: There is an above ground pool on the premises of the home inaccessible to children behind lock gate on side yard. Licensee stated there are no firearms or other dangerous weapons. LPA observed glass screen fireplace inaccessible to children. Fire extinguishers, smoke detectors, and carbon monoxide are operable at time of inspection. LPA observed the home to be orderly, central air and heating available.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

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 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: COTTAGE FAMILY CHILD CARE	FACILITY NUMBER: 197416069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)1

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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review], the licensee did not comply with the section cited above to document fire drills and disaster drills] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2022
	Plan of Correction
1 2 3 4	Licensee will forward a copy of the document fire drill and disaster drill for this month.

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: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC809 (FAS) - (06/04)

Page: 5 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: COTTAGE FAMILY CHILD CARE	FACILITY NUMBER: 197416069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2022

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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not renewing mandated reporter training certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2022
	Plan of Correction
1 2 3 4	Licensee will forward a copy of current mandated reporter training certificate to LPA.

Type B

Section Cited

HSC

1596.8662(c)

Administration of Child Day Care Licensing

(c) Current proof of completion for each licensed child day care provider or applicant for that license, administrator, and employee of a licensed child day care facility shall be submitted to the department upon inspection of the child day care or upon request by the department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited aboveStaff had not completed the mandated reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2022
	Plan of Correction
1 2 3 4	Licensee will forward a copy of staff mandated reporter training certificate to LPA.

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: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC809 (FAS) - (06/04)

Page: 7 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: COTTAGE FAMILY CHILD CARE	FACILITY NUMBER: 197416069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102370(d)(2)

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: (2) Request a transfer of a criminal record clearance as specified in Section 102370(j) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above by not having staff #1 transfer of a criminal record clearance to the licensee's day care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/13/2022
	Plan of Correction
1 2 3 4	Licensee will sulbmit the LIC9182 to the department to associate staff #1

Type B

Section Cited

CCR

102416(c)

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:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above staff 1 did not have a current cardiopulmonary resuscitationCPR and pediatric first aid card or certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2022
	Plan of Correction
1 2 3 4	Licensee shall forward a copy of staff current cardiopulmonary resuscitationCPR and pediatric first aid card or certificate

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: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC809 (FAS) - (06/04)

Page: 6 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: COTTAGE FAMILY CHILD CARE	FACILITY NUMBER: 197416069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(a)

Immunizations

(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in 2 out of 3 children records did nto have current immuniztion records, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2022
	Plan of Correction
1 2 3 4	Licensee shall forward a copy of child 1 and 2 immuniztion record.

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: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC809 (FAS) - (06/04)

Page: 8 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: COTTAGE FAMILY CHILD CARE	FACILITY NUMBER: 197416069
	VISIT DATE: 01/13/2022

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

There is a landline telephone and a cell phone available for the license day care. No crib or play pen for infants were observed at the day care. Licensee is aware all cribs or play pen shall have a firm mattress. Licensee stated she is not currently caring for any infants.

LPA discussed safe sleep regulation and informed licensee to refer to regulation 102425(J) for documentation requirement. LPA reviewed requirement with licensee during this inspection. Licensee shall supervise infants while they are sleeping by physically checking every 15 minutes and documenting the child status in writing. Licensee was informed all infants shall have an individual infant Sleeping Plan (LIC 9227). Licensee aware no infant shall be swaddle, car seat shall not be used for sleeping, LPA provided Child Care Licensing Safe Sleep webpage as an additional resource: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
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 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

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC809 (FAS) - (06/04)

Page: 4 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: COTTAGE FAMILY CHILD CARE	FACILITY NUMBER: 197416069
	VISIT DATE: 01/13/2022

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

(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

Care and Supervision
Licensee is aware she must be present in the home 80% of the time and shall ensure that children in care are supervised at all times. Licensee states she provides transportation. LPA informed licensee to make sure the transportation vehicle is proper insured to transport day care children. Licensee is aware the capacity stated on the facility license shall be the maximum number of children being cared for at one time.

Facility Records Review
LPA did not observe current fire and disaster drill, and current mandated reporter training certificate for licensee or assistance. Licensee is aware that all employees or volunteer at the day-care shall be immunized against pertussis and measles and maybe immunized against influenza.

Facility Administration
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.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC809 (FAS) - (06/04)

Page: 3 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: COTTAGE FAMILY CHILD CARE	FACILITY NUMBER: 197416069
	VISIT DATE: 01/13/2022

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

Licensee aware to immediately remove individual and prevent individual for returning to the home or having contact with children in care upon notice from the department to remove an individual and all individuals subject to a criminal record review shall obtain a criminal record clearance or exemption prior to working, residing or volunteering in the license home. Licensee is aware any authorized employee of the Department may enter and inspect any place providing personal care and services at any time with or without advance notice. Licensee is aware other personnel shall complete training on preventive health practices including CPR and first aid per regulation 102416 (c). Licensee CPR and first aid card expires 08-22-2022.

Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in writing within 7 day of incident on the form LIC624B per the regulation.
During this inspection facility was observed not to be in compliance with Title 22. Please see LIC 809D for deficiencies.
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.
Exit interview conducted and report was reviewed with the licensee a copy of this report and a notice of site visit was given and must remain posted for 30 days

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC809 (FAS) - (06/04)

Page: 2 of 8