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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493367
Report Date: 06/11/2019
Date Signed: 06/17/2019 07:17:40 AM

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:BENAVIDES FAMILY CHILD CAREFACILITY NUMBER:
197493367
ADMINISTRATOR:BENAVIDES, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 201-7091
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:14CENSUS: 6DATE:
06/11/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
07:35 AM
MET WITH:Ana BenavidesTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Silva Garibyan conducted a site visit for the purpose of an Annual Random visit. LPA met with the licensee and toured the home inside and outside at 7:45 AM on 06/11/2019. There were 6 children ( including three infants) present at the time of the visit. Licensee was present with one assistant ( associated to the facility). All areas identified on the facility sketch were inspected. Licensee's home is a single story, 4 bedroom, 2 bathroom home with a living/dining room, kitchen, and detached converted garage. The living/dining room, kitchen, the two bedrooms in the hallway, the bathroom in the master bedroom, and the detached garage are off limits to the children in care. There is no pool, spa or other bodies of water on the premises. The main entry door is not used to enter the facility. Parents and children use the side door leading to the bedroom/play room. Family members residing in the home include 6 adults (licensee, spouse, her parents, and her cousin/tenant, licensee's grandmother). The children have access to the bathroom in the hallway. There are age appropriate toys and equipment for the children. LPA also observed Licensee's assistant's current Pediatric CPR (Adult/Infant /Child) and Pediatric First Aid certifications (expire 03/2020). Licensee was unable to demonstrate current proof of CPR/First Aid Certificates ( expired 04/2019). The LPA toured all areas used by children during this inspection. The bathroom and the kitchen was observed free of chemicals or toxic items that can pose danger to children in care. The outdoor play area was inspected. Children's outdoor play equipment and toys are age appropriate and in good repair.. LPA observed the yard to be fully fenced. The Fire Extinguisher (2A-10-BC) is mounted on the wall in the play room. There is a working smoke/carbon monoxide detectors located in the living room. The First Aid kit was observed, and complete. LPA observed the fire drill log. The fire drills are done every month. Children utilize the side yard. The back yard is off limits to the children in care.
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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: BENAVIDES FAMILY CHILD CARE
FACILITY NUMBER: 197493367
VISIT DATE: 06/11/2019
NARRATIVE
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Licensee has the following documents posted in the FCCH; Facility License (LIC 203), Notification of Parents' Rights Poster (PUB 394) , Child Care Facility Roster (LIC9040), Emergency Disaster Plan (LIC610a).
A review of the children's records was conducted and are found to have the following: LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization Card.

The following was thoroughly discussed with the licensee:

Assembly Bill 633: Upon receipt by the licensee, licensees are to provide to parents/guardians the following: Copies of any licensing reports that document a Type A citation- this includes facility visits and substantiated complaint investigations; copy of licensing documents pertaining to a conference conducted by a local licensing agency management representative and the licensee of this family child care home in which issues of noncompliance are discussed or copies of a summary of an accusation indicating the Department's intent to revoke the facility's license. Copies of any of the above licensing documents the licensee has received in the prior 12 months shall be provided to parents/guardians of newly enrolled child at the facility.
Senate Bill 792: This bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles. Licensee's and assistant's immunization records are up to date. .
New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment

New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: BENAVIDES FAMILY CHILD CARE
FACILITY NUMBER: 197493367
VISIT DATE: 06/11/2019
NARRATIVE
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Update on Incidental Medical Services:

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

Mandated Reporter: Beginning on January 1, 2018, AB 1207, 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. Volunteers are encouraged but not required to take the training. Website: www.mandatedreporterca.com.




Facility was cited one Type B deficiency. See Facility Evaluation Report LIC 809-D for deficiencies cited.
A Copy of this Report and Notice of Site Visit were provided to the licensee.

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: BENAVIDES FAMILY CHILD CARE
FACILITY NUMBER: 197493367
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2019
Section Cited
CCR
102416(C)
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Licensee is required to maintain current Pediatric CPR and First Aid certifications at all times..
This requirement is not met as evidenced by: Licensees was unable to demonstrate current proof of CPR/First Aid Certificates ( expired 04/2019)
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Licensee will provide proof of current Pediatric CPR & Pediatric First Aid certifications or registration for by 06/25/19
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This poses a potential risk to the health and safety of children in care
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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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
LIC809 (FAS) - (06/04)
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