197416481-11-8-2023-12-CC-MRIA-CXE3HY-20231108171643

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197416481
Report Date: 11/08/2023
Date Signed: 11/08/2023 05:17:01 PM

Document Has Been Signed on 11/08/2023 05:17 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	SHIRLEY FAMILY CHILD CARE		FACILITY NUMBER:	197416481
ADMINISTRATOR:	SHIRLEY, KIMBERLY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 904-7211
CITY:	SAUGUS	STATE: CA	ZIP CODE:	91350
CAPACITY:	14	CENSUS: 12	DATE:	11/08/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jasmine Barila, Assistant		TIME COMPLETED:	05:30 PM

NARRATIVE

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On Wednesday, November 8, 2023, at 2:30 p.m., Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with assistant Jasmine Barila who guided LPA Rivera on a tour of the facility.

Family members residing in the home have been discussed with assistant and are cleared. LPA observed 3 infants and 8 preschool children present. LPA observed facility to be within ratio. Operating hours are Monday to Friday from 7:00 a.m. to 5:00 p.m. and care for children ages 0 to 5 years old.

This facility is a two-story home that consists of 4 bedrooms, 3 bathrooms, kitchen, living room, dining room, laundry room, and front and backyard.

Areas off limits to children include- All second floor (barricaded with installed safety gate), bedroom, and bathroom (in bedroom) located first floor near the entrance hallway, kitchen, laundry room, pool area.

Areas accessible to children include living room, dining room, bathroom located in the hallway and backyard.

At approximately 2:43 p.m., LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Rivera observed central AC and the vents located on the ceiling. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA observed a fireplace and observed a childproof lock on the screen. Per licensee, the fireplace has not been turned on and is off and requires a key to turn on. LPA observed 3 play pens and observed to be free from bumper pads, blankets, pillows and hanging items.

LPA Rivera observed cleaning compounds items and knives sharp objects stored in the laundry room. LPA observed the door closed and locked with a key. For water drinking, LPA observed water filtered and sippy cups. The assistant stated the facility provides a.m. snack, lunch, and p.m. snack. LPA informed assistant

SUPERVISOR'S NAME: Lady King	TELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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 11/08/2023 05:17 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2023

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in not documenting infant sleep logs which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	For children under the age of 2, complete daily the sleep logs and will begin tomorrow 11/9/23, and submit proof by due date.

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: Lady King	TELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 11/08/2023

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any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. Assistant stated she currently does not have any children with severe food allergies and has two children with prescribed Albuterol and Fluticasone Propionate and LPA observed both medications to expire in March 2024.

At approximately 2:53 p.m., LPA Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA did not observe hazard materials and observed the bathroom to be in good condition. LPA reminded licensee and personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Rivera asked the assistant if there were any pets, poisons, firearms, weapons, or bodies of water. The assistant stated she has one dog and a turtle, poisons, and body of water. No firearms, and no weapons. LPA observed one dog, poisons, and in- ground pool in the backyard. LPA observed the pool area to have a mesh fence and does not cover all around. The other side to complete the coverage is a brick wall. There are no windows on the side of the brick wall. LPA measured the height of the fence from the ground up to the top of the fence to be 5.0 ft high and fence does not obscure the pool from view. The openings of the railings, LPA measured and observed the openings to be 3 inches wide. LPA observed the door to swing away from the pool and the self-latching device is no more than 6 inches from the top of the gate.

LPA observed the poisons to be stored in the laundry room and the doorknob is locked. LPA reminded that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition must be stored separately.

LPA Rivera observed the required 2A10BC fire extinguisher located in the dining room and the valve on the green area indicating fully charged. LPA did not observe a service tag or a purchase receipt. LPA reminded licensee and assistant the fire extinguisher must be serviced annually or purchase one yearly. LPA observed carbon monoxide detector in the laundry room and smoke alarm located in the hallway. LPA tested the carbon monoxide and smoke alarm. LPA Rivera heard the sounds and are operable. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic wipes and located in the daycare room top cabinet. For ill isolation, assistant stated she utilizes a corner of the daycare room. LPA observed the last emergency drill conducted on 10/3/23.

SUPERVISOR'S NAME: Lady King	TELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 11/08/2023

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At approximately 3:00 p.m., LPA Rivera inspected the play outdoor (backyard) area that is utilized by children for safety, comfort, and cleanliness. LPA observed the backyard to be fenced and side gates closed and with a self-latch. LPA observed the play equipment to be age appropriate and in a safe condition, free of sharp, no lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA recommended to place a mesh cover on the AC compressor. For outdoor water drinking, children bring out their water bottles.

LPA Rivera observed licensee American Heart Association Instructor certification dated 9/21/23. and licensee has proof of immunization against Pertussis, MMR, and Influenza. Licensee has not completed the Child Abuse Mandated Reporter (AB 1207) training. Licensee was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

LPA observed the postings License, LIC 9148 Earthquake Preparedness Checklist, LIC 610A Emergency Disaster Plan, and Pub 394 Notification of Parents Rights. LPA also reviewed children’s roster, children, and staff files. LPA did not observe safe sleep logs.

The following was also discussed with the licensee:

1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2 Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present.

3. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

SUPERVISOR'S NAME: Lady King	TELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 11/08/2023

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4. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.
5. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated

6. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

7. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

8. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B). Mandated reporter requirements were reviewed and explained.

9. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

10. Smoking is prohibited in the family childcare home.

11. Children and staff records must be maintained and updated as needed and be available for review by the Department.

12. Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children have proof of immunizations.

13. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

14. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

SUPERVISOR'S NAME: Lady King	TELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 11/08/2023

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15. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

16. Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

17. Dog(s) and/or pets are recommended to be isolated from children in care.

18. No baby bouncers, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.

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.

Assistant Jasmine Barila 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.

LPA discussed the safe sleep regulations with assistant Jasmine Barila 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 assistant Jasmine Barila 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.

SUPERVISOR'S NAME: Lady King	TELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 11/08/2023

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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.

Family Child Care Homes assistant Jasmine Barila 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.

During the exit interview, assistant Jasmine Barila, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The deficiency listed on the following page was observed by LPA Rivera and is being cited in accordance with California Code of Regulations Title 22. One type B deficiency is being issued today for regulation 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:. Please see attached LIC 809-D for citation.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted, and report was reviewed with the assistant Jasmine Barila.

SUPERVISOR'S NAME: Lady King	TELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

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