197417251-7-13-2021-30-CC-ARAZ-C4VW5E-20210713165900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197417251
Report Date: 07/13/2021
Date Signed: 07/13/2021 04:59:09 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:	AGAYBY FAMILY CHILD CARE		FACILITY NUMBER:	197417251
ADMINISTRATOR:	AGAYBY, GERMIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 237-5768
CITY:	ENCINO	STATE: CA	ZIP CODE:	91316
CAPACITY:	12	CENSUS: 11	DATE:	07/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:51 AM
MET WITH:	Germin Agayby		TIME COMPLETED:	11:17 AM

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 7/13/2021 at 9:51 AM Licensing Program Analyst (LPA) Angelica Ramirez, conducted an unannounced Annual Required Inspection and was met by Licensee, Germin Agayby. Prior to entering the home, LPA Ramirez confirmed with licensee that no one in the home has experienced any COVID-19 symptoms within the last 14 days. LPA also informed licensee that LPA has not experienced any symptoms within the same time frame. Also present was Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). Days and hours of operation are Monday through Friday 9 am to 5 pm.

LPA toured the home inside and outside and a census was taken. LPA Ramirez observed 11 children with licensee and Staff. Current facility sketch reviewed and Licensee confirmed that the living room, hallway bathroom, and three bedrooms are used for providing care and are accessible to children. There is a backyard and patio that are accessible to children in care. There is an additional detached room located in the backyard that is used by children with a working bathroom. LPA reminded licensee that there is to be no eating or napping in this room as it does not have a permit. There is air conditioning in this detached room. There is a bathroom located in the master bedroom along with a small storage closet within that are off limits to children in care. The kitchen is also off limits (with a gate) and a storage shed in the backyard made inaccessible with a latch. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There is no fireplace on site. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is 310-237-5768.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Angelica Ramirez	TELEPHONE: (424) 301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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 3

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: AGAYBY FAMILY CHILD CARE	FACILITY NUMBER: 197417251
	VISIT DATE: 07/13/2021

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 are currently two infants in care. LPA discussed Safe Sleep Regulations with licensee and reminded licensee that no children (including infants), should sleep behind a closed door. Sleeping children should be monitored and infants must sleep on their backs. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

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. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training expired in March of 2018 and will be renewed by 7/19/21. A copy will be provided to LPA Ramirez and added to the file. Licensee’s pediatric CPR/First Aid expires on 7/28/22. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Angelica Ramirez	TELEPHONE: (424) 301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: AGAYBY FAMILY CHILD CARE	FACILITY NUMBER: 197417251
	VISIT DATE: 07/13/2021

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

During today's inspection LPA Ramirez inspection all rooms and LPA has requested an updated facility sketch that includes accessible rooms and detached room in backyard. Licensee shall provide the updated copy to LPA Ramirez by 7/19/2021.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

This report shall be made available to the public upon request. A copy of this report and LIC 9213 Notice of Site Visit will be provided to the licensee and the Notice of Site Visit is required to be posted for 30 days.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Angelica Ramirez	TELEPHONE: (424) 301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3