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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493599
Report Date: 05/09/2019
Date Signed: 05/09/2019 03:25:58 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:MEMBRENO FAMILY CHILD CAREFACILITY NUMBER:
197493599
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
05/09/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Angela MembrenoTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Marina Pilossian conducted a site visit for the purpose of an Annual Random visit . The licensee has applied for capacity increase. LPA met with the licensee and toured the home inside and outside at 1:48pm on 5/9/19. The licensee, and her adult daughter who is also the assistant were present with 6 children ( 2 infants, 2 school age, and 2 pre school age) children. LPA observed some of the children napping in the bedroom, and some awake playing. The licensee has installed the pull fire alarm that is required for large Family Child Care Homes and has an approved fire clearance. All areas identified on the facility sketch were inspected. Applicant has a small dog (Maltese).

This is a single family, single story home (5 bedrooms, 2 bathrooms, living room, dining room, kitchen, a detached garage, and pool) The home was inspected inside and out. Family members residing at facility are: applicant, spouse, and 2 adult children. The home was inspected 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.

Applicant will primarily care for children in the bedroom/play room accessible from the side of the home that is closest to the back yard.. Licensee will also utilize the 2nd bedroom that is adjacent to the bedroom used by the children. Children will have access to the bathroom that is adjacent to the bedroom located the hallway. The three bedrooms and one bathrooms are off-limits. There is an in-ground pool that was observed to be fenced off completely by a mesh fencing that surrounds the pool. It was observed to be at least 5 ft. high, with a gate that was tested to open away from the pool and was self latching/self closing.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
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: MEMBRENO FAMILY CHILD CARE
FACILITY NUMBER: 197493599
VISIT DATE: 05/09/2019
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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. Licensee and assistants have completed the training.

The licensee was informed of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541


Email Address: childcareadvocatesprogram@dss.ca.gov
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
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: MEMBRENO FAMILY CHILD CARE
FACILITY NUMBER: 197493599
VISIT DATE: 05/09/2019
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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.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
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: MEMBRENO FAMILY CHILD CARE
FACILITY NUMBER: 197493599
VISIT DATE: 05/09/2019
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Capacity and Ratios: The licensee has applied for a capacity increase for a large family . The Max capacity is 12 with no more than 4 infants and a qualified assistant. Without a qualified assistant the license reverts back to the requirements for a small family childcare. Optional care may be provided for a max capacity of 14 children with no more then 3 infants, 2 school age children and a qualified assistant. School age children must be 1 age 6 yrs and 1 in Kindergarten.


The facility is operating in substantial compliance with the Title 22 Regulations at time of visit.
No violations were cited. A copy of this report along with a Notice of Site Visit were issued and explained to licensee.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MEMBRENO FAMILY CHILD CARE
FACILITY NUMBER: 197493599
VISIT DATE: 05/09/2019
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Per applicant, there are no weapons or firearms of any kind in the facility at this time. The LPA did not observe any weapons.. There are age appropriate toys and equipment on the premises. The required fire extinguisher (2A 10BC) (mounted in the kitchen) and smoke/carbon monoxide detectors are in operable condition. CPR and First Aid expire 11/2019.

LPA Pilossian toured the outdoor area. The front yard is not fenced and children will not play in the front yard, however, the back yard is fully fenced with a pool. There is also an area in the back yard with a gate. LPA observed a brick wall and added wire fence to make the entire wall 7 ft. tall to make the Tujunga Rush in accessible to the children. Behind the wall/ fence there is the Tujunga rush and a steep area that leads to the Tujunga rush channel. The gate on that wall, has no lock. Per licensee, fire Department informed the licensee as long as the self latching lock is placed on the other side of the gate, then the children will not have access to the self latching lock. LPA informed licensee to lock the gate to prevent school age children that can reach the self latching lock. Licensee understands and will comply. LPA measured the wall fence, and additional wire fence and it appeared to be over 7 feet. LPA Pilossian explained to the applicant to not place any chairs or tables or any other similar kind of objects that children can climb on it to prevent the children from having access to the area. The detached garage is locked and used for storage. Children will not have access to the detached garage. LPA observed a sand box in the back yard to be utilized by the children.

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).


SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5