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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492761
Report Date: 07/26/2022
Date Signed: 07/27/2022 08:50:15 AM


Document Has Been Signed on 07/27/2022 08:50 AM - 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



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: 1DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Nicole ShelleyTIME COMPLETED:
10:45 AM
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On 07/26/22 Licensing Program Analysts(LPAs) Justeene Tamayo and Barbara Beneroso met with Licensee, Nicole Shelley who guided analyst on a tour of the facility for the One Year Required inspection. This is a one story, 3 bedroom, 2 bathroom home with kitchen/dining, living room, back den room, laundry room and garage. There is no pool/spa or body of water on the premises. Upon arrival LPA observed 1 child in care. Licensee currently does not have any infants enrolled, but does understand the requirements. Family members residing in the home include 2 adults (licensee, licensee husband) and three children. Facility operation are Monday-Friday 9PM-6PM. Incidental Medical Services (IMS) policy was discussed.

Physical Plant: Main care is provided in the back den area. Children use the bathroom in hallway on the right. Children have access to the den area (children's playroom) and backyard. Off limit areas include all bedrooms, living room, bathroom #2, laundry room, and garage. The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounnds (laundry room), medicines (master bedroom) and hazardous items (sharp knives in kitchen drawer) that can pose a danger to children. LPAs observed a safety gate barricading the kitchen as well as the hallway area leading to the laundry room and off limit bedrooms. LPAs observed a fireplace in the home screened in the living room. Safe and age appropriate toys, play equipment and materials were observed. The smoke detector and carbon monoxide detector, Fire Extinguisher (2A10BC) are in operable condition. Per Licensee no one smokes in the home. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment were observed on the premises. There is a designated area for ill children as necessary in the dining area. Per Licensee there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (cell).
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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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: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 07/26/2022
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Last Fire/Disaster Drill was completed on 08/20/2019. LPAs reminded licensee, she must conduct a Fire/Disaster Drill every 6 months, and document the date and time of each drill. Facility has been cited a Type B Citation. Please see LIC 809-D.

Roster complete and maintained current.

Bathroom: Shower/tub are free of hazards (child care bathroom). LPAs did not observe any hazardous items in the children's bathroom. Toilet and faucet are clean and operable.

Kitchen: Sharp utensils, open bottles or alcohol are inaccessible. If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. The home has a clean and fully stocked refrigerator/freezer. Cleaning supplies are in laundry room. Breakfast, lunch, and snacks are provided.

Outdoor: The backyard is safe for children. The backyard is completely fenced (with wooden gate). There is no body of water. LPAs reminded licensee to pick up dog feces before children have access to the backyard area for playtime. LPAs observed age appropriate toys and play equipment. Per licensee, there is one pet on the premises. LPAs observed assistant #1 in the backyard cleaning. Assistant #1 is fingerprint cleared and associated. The back den leading to the backyard has an alarm system when door is opened.

Advisory/Other: First Aid kit was observed with supplies readily available. CPR/First Aid expire 04/15/2024. Mandated Reporter expires 04/15/2024. There are no window cords accessible to children.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 07/26/2022
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Documents Provided and or Discussed: Fire Drill Log, Postings, Safe Sleep PIN 20-24-CCP, Individual Sleeping Plan LIC 9227. Licensee has no children in care during the inspection, however, one file was reviewed for information. Licensee stated currently does not have child care insurance.

Licensee Shelley 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.

LPAs discussed the safe sleep regulations with licensee Shelley and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPAs 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.

A notice of site visit was given to licensee and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Nicole Shelley along with her appeal rights.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/27/2022 08:50 AM - 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. Last fire/disaster drill was completed on 08/20/2019, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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Licensee will conduct a fire/disaster drill no later than 08/11/22 and send a copy to LPA Tamayo. LPAs reminded licensee, a fire/disaster drill must be completed and documented every 6 months.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
LIC809 (FAS) - (06/04)
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