<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492761
Report Date: 06/21/2019
Date Signed: 06/21/2019 11:30:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:SHELLEY FAMILY CHILD CAREFACILITY NUMBER:
197492761
ADMINISTRATOR:SHELLEY, NICOLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 878-1429
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:14CENSUS: 7DATE:
06/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Nicole ShelleyTIME COMPLETED:
10:45 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
Licensing Program Analyst (LPA) Lady King-Lewis conducted an Annual Random inspection at the above facility. Upon arrival LPA was greeted by licensee, Nicole Shelley. LPA observed 7 children. A copy of Child Care Facility Roster was emailed to LPA. LPA observed all 7 children files contained children immunization records and signed copy of Notification of Parents Rights. Per Licensing Information System (LIS) all adults residing and working in the home have obtained background clearances. Per LIS, facility annual fees are current. The licensee is operating within proper capacity and ratios. LPA observed licensee and assistance to be present at the home and providing adequate care and supervision.

The home is clean, orderly, comfortable and well ventilated. Licensee's poisons, detergent, cleaning compounds, medications and other items which could pose a danger to child are stored where they are inaccessible to children. LPA observed working smoke detector and Carbon Monoxide, fully charged 2A10BC fire extinguisher and working telephone. There are several age appropriate toys and a first aid kit on the premises. The day care takes place in enclosed patio room, dinning area, hallway bathroom and rear yard. The backyard is completely fenced in. There are no bodies of water in the FCCH. Per the licensee, there are no firearms on the premises.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 06/21/2019
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
The licensee has current CPR and first aid that expires, 11-19-19. .

The licensee has taken the mandated reporter training.



The licensee has the required immunization's.

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 (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

The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).

The licensee was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov i

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
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, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 06/21/2019
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
Our Quarterly updates come out every 3 months they are also now in Spanish please log in to the CCLD website or you can email our advocates to have the quarterly updates send directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

Per the licensee, fire and disaster drills are conducted monthly; last drill documented and conducted on 08-22-19.

Licensee has the required documents posted in the FCCH; Facility License (LIC 203), Emergency Disaster Plan (LIC610a), Notification of Parents' Rights Poster (PUB 394).

The following was discussed with the licensee;


No smoking, No infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category, earthquake safety and necessity of drills (every 6 months), required forms for children’s files, facility files, posting requirements, penalty, fingerprint clearance, and the transfer process and penalty. For additional information and forms visit our website at: www.ccld.ca.gov

Licensee is aware of CCLD child care videos on Community Care Licensing website at: https://ccld.childcarevideos.org/

The following deficiency cited in accordance to Title 22 of the California Code of Regulations and/or Health & Safety codes.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
LIC809 (FAS) - (06/04)
Page: 3 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, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 06/21/2019
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
An exit Interview was conducted, a copy of this Report and a Notice of Site visit was provided to the licensee.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
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, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550

FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2019
Section Cited
CCR
102416.3(a)(2)
1
2
3
4
5
6
7
Alterations to Existing Buildings or Grounds- Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: Room additions to the family child care home. This requirement is not met as
1
2
3
4
5
6
7
Licensee shall write a statement stating she is aware that any changing with the day care in the future the department and the assigned LPA will be notified. (hours of operation, change of location, injuries and emergency, etc.)
8
9
10
11
12
13
14
 evidenced by: LPA observed newly constructed enclosed patio near rearyard, the daycare has transition from bedroom 1 to the enclosed patio without notifying CCL or assigned LPA. of the construction work or the transition. which posed a potential health and Safety risk to children in care. Licensee stated the enclosed patio was permitted by Lancaster Planning Dept. and a copy of permit was provided to LPA.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5