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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493032
Report Date: 09/20/2022
Date Signed: 09/20/2022 11:20:45 AM


Document Has Been Signed on 09/20/2022 11:20 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:FLORES FAMILY CHILD CAREFACILITY NUMBER:
197493032
ADMINISTRATOR:FLORES, PAULYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 391-9276
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:14CENSUS: 0DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Pauly FloresTIME COMPLETED:
11:25 AM
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On 9/20/2022 Licensing Program Analysts (LPA) Isabel Ortega conducted an unannounced annual random inspection. The LPA disclosed the purpose of the inspection and was granted entry by Licensee who guided the LPA on a tour of the facility. Upon entry to the facility the LPA did not observe any children in care.

This is a one-story single-family home. There is a living room, den, kitchen, 4 bedrooms, 3 restrooms, one small shed in the back yard (utilized for emergency supplies and food) and an attached garage. Main care is provided in the living room and den referred to as the child care area. The off-limits areas are the 4 bedrooms, two restrooms, one sheds in the back area (key locked) and attached garage (maintained locked). Children utilize the back yard for outdoor play. The back yard is fenced all around, there is a second play yard divided in two separate sections. The operational child care hours are Monday through Friday from 7:00 a.m. to 5 p.m.
The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Cleaning supplies and chemicals are inaccessible to children in care.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Isabel OrtegaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 197493032
VISIT DATE: 09/20/2022
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There are age appropriate toys and equipment on the premises. Per the licensee there are no weapons or firearms of any kind in the facility. The LPA did not observe any weapons.
The First Aid kit with a temperature thermometer was observed and complete. The required fire extinguisher (2A10BC) is reading in green. Smoke and carbon monoxide detectors(dual) were found to be in operating condition tested at 10:09a.m.. Fire and disaster drills are conducted every six-month, last recorded June 8,2022 at 4:00 p.m.

Licensee had all the required posted documents: Facility License (LIC 203, Notice of Parent's Rights Poster (PUB 394), Emergency Disaster Plan (LIC 610A), and Earthquake Preparedness Checklist (LIC 9148)

The licensee provided proof of immunization against pertussis (TDAP), measles (MMR), and influenza.


CPR/First Aid expires 9/13/2024. Mandated Reporter training certificate is dated 4/13/2021
Currently licensee does not have any children enrolled and once a child is enrolled , licensee is are child roster shall be completed and maintained current.

The following were discussed: No smoking, infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category are permitted in the facility. The LPA also discussed earthquake safety and necessity of drills, required forms for children’s files, facility files and posting requirements and penalty.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Isabel OrtegaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
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: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 197493032
VISIT DATE: 09/20/2022
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The licensee was informed that all adults living in or having access to the home are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please advise your analysis of any person who will be visiting regularly or for longer than one week.

The Licensee was reminded to report Unusual Incidents. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. The applicant was informed to utilize the Unusual Incident Report/Injury Report form LIC624B when submitting the report to the department. email

Safe Sleep regulations (under 24 months) were discussed with Licensee and referred to the CCL web site for additional information and PINS. Provided licensee with an infant sleep plan form LIC 9227 and sleep log.
Beginning on January 1, 2018, Assembly Bill 1207 (2015) requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Applicants must meet requirements as a precondition to licensure. New employees shall have 90 days from date of employment to complete training as required. The training may be conducted at the following website www.mandatedreporterca.com.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Isabel OrtegaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
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: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 197493032
VISIT DATE: 09/20/2022
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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

Child Care Advocates:


To sign up for our Quarterly Updates please email the Child Care Advocates at
chilcareadvocatesprogram@dss.ca.gov & (916) 654-1541

The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000.

The facility was found to be in compliance per Title 22 regulations, no deficiencies will be cited today. An exit interview was conducted, a copy of this Report and a Notice of Site visit was provided to the licensee. Appeal rights were provided and discussed with licensee.

SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Isabel OrtegaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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