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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494080
Report Date: 12/20/2019
Date Signed: 12/20/2019 03:22:51 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:AMADOR FAMILY CHILD CAREFACILITY NUMBER:
197494080
ADMINISTRATOR:AMADOR, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 674-7261
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:14CENSUS: 8DATE:
12/20/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Jennifer AmadorTIME COMPLETED:
12:57 PM
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Licensing Program Analyst (LPA), Keyona Scott, conducted an unannounced Annual Random Inspection to ensure the health and safety of the Child Care Home according to Department Regulations and Health and Safety Codes. LPA arrived at the facility location at 8:40 AM. LPA met with Licensee's Assistant, Veronica Martinez-Romero at 10:20 AM and observed eight children in care, which includes three infants. Licensee, Jennifer Amador arrived at the facility at 10:40 AM and LPA was guided on a tour inside and outside of the home. There are no changes to the facility layout or to the off-limit areas of the family child care home.

Present during the inspection was ID# 7509021753 (Adult #1). Adult # 1 has obtained a livescan, however, did not receive a criminal record clearance. In order for Adult #1 to work or be present in the home, Adult #1 must obtain a criminal record exemption. Per Licensee, Adult #1 was only present for the day (12/20/2019) to assist in running errands and helping with Christmas program on 12/20/2019. Adult #1 has failed to request a criminal record exemption and does not have a criminal record clearance to work or be present in the facility; which poses an immediate risk to the health, safety and/or personal rights of the children in care.

Licensee's mother (Adult #2) was also present in the home during the inspection. Per Licensee and Adult #2, Adult #2 is visiting for the holidays. LPA advised Licensee, if Adult #2 or any visitor will be present in the home for more than 30 days, then such visitor is required to obtain a livescan.

Adults present in the home that are cleared and associated to the facility are Licensee and Licensee's Assistant.


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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
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 7
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: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 197494080
VISIT DATE: 12/20/2019
NARRATIVE
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The home is a one story, three bedroom, one bathroom home with an open living room, dining room, kitchen area and an attached garage. Per Licensee, no child care is conducted in the attached garage. The off-limit area of the home is the master bedroom. The master bedroom is made inaccessible by closed door with safety gate at hallway entrance to the master bedroom. The primary child care area is in the open living room, dining room area of the home. LPA observed cubbies, table and chair sets, puzzles and activity sets in the primary child care area. The children also utilize the toy room located through the hallway to the right, second bedroom on the left. LPA observed cubbies, toys, kitchen play set, chair and bookshelf with books in the toy room. The baby room located through the hallway on the left is used as a napping room for infants under 24 months. LPA observed four play yards and cubbies in the baby room. Children utilize the bathroom located through the hallway to the rear. LPA observed safety latches on the cabinets in the kitchen.

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. Home utilizes a screened wall heater as a source of heat and a ceiling fan and air conditioner as cooling sources. Home has a working telephone. Hazardous materials in the kitchen and bathroom are inaccessible to children. According to the licensee, there are no weapons or firearms at the home; None were observed by LPA. There is a pet dog in the home that remains inaccessible to children in care during operation hours.

The home is equipped with a fully charged fire extinguisher which is at least a 2A:10BC. The home is also equipped with at least one working smoke detector. There is a working carbon monoxide detector in the home. There is also a first aid kit equipped in the home. LPA observed current First Aid and CPR certificates for Licensee with an expiration date of 08/04/2020 and Licensee's Assistant with an expiration date of 05/04/2021. Licensee also completed Mandated Reporter training on 09/25/2018.



Toys and playthings are safe, orderly and age-appropriate for the children. Licensee agrees that no baby-walkers, bouncers, jumpers, exersaucers and similar items will be used for children in care and are kept inaccessible; None were observed by LPA.
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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 197494080
VISIT DATE: 12/20/2019
NARRATIVE
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Outdoor play area is fenced in and also is free from defects or dangerous conditions. Outside toys and playthings are safe, orderly and age-appropriate for the children. No pools, spas, hot tubs, fish ponds, or similar bodies of waters observed during the inspection.

LPA observed current Child Care Facility Roster of the children enrolled. There are currently nine children enrolled at the facility.

The facility operation hours are Monday through Saturday, 24 hours.

Licensee states is not providing IMS (Incidental Medical Services) services at this time.

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


Incidental Medical Services Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering EpiPen Jr. and EpiPen or other Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Emptying an Ileostomy Bag.

The following was thoroughly discussed with the licensee:


All adults living and working in the home must be fingerprinted and cleared prior to entering the facility. 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 including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507.

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 197494080
VISIT DATE: 12/20/2019
NARRATIVE
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Licensee was reminded it is the Licensee’s responsibility to know the regulations as well as anyone who assists in providing care. Licensee was advised on how to access quarterly reports, forms, and regulations for Child Care online at www.ccld.ca.gov. Licensee was also encouraged to read the Child Care quarterly updates every season as the come out to stay informed of any changes or updates to the regulations.

Senate Bill 792: Commencing September 1, 2016, SB 792, 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. LPA discussed the influenza waiver during the inspection.

Licensee informed Fire Disaster Drills are to be conducted at least once every month and log must be kept.

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 within 24 hours of the Unusual Incident and follow up with a written Unusual Incident/Injury Report (LIC 624B) within 7 business days.



Licensee was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome

The licensee was also recommended the following Safe Sleep Practices: always place infants on their backs for sleeping; use only a tight-fitting sheet on the crib or play yard mattress; do not hang any items from the crib or above the crib; keep all items, including blankets, out of the crib or play yard; pacifiers may be used as long as they do not have items attached to them; infants should not be swaddled or have any items covering them while sleeping; the temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold. Please note, these guidelines are recommendations for best practices only, until regulations are approved and adopted.

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 197494080
VISIT DATE: 12/20/2019
NARRATIVE
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The licensee was advised that, once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed.

Licensee was provided the following forms/brochures:


PUB 271: Preventing Shaken Baby Syndrome/Abusive Head Trauma
PIN 19-10-CCP U.S. Consumer Product Safety... Fisher-Price Infant Equipment Accessory Recall
PIN 19-12-CCP U.S. Cosumer Product Safety... Infant Sleeper Recall
PIN 19-09-CCLD Division Mailchimp Account Information... Subscribe For Updates
SafeBaby2indd- Safe Sleep

The facility was not operating in substantial compliance during today's inspection on 12/20/2019. The facility was cited for Title 22 deficiencies and civil penalties during this inspection. Please see LIC 809-D of this report for further details.

LPA discussed AB633 and informed licensee that, upon receipt of a Type A deficiency, the licensee shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Licensee was advised that each parent or child representative must sign the LIC 9224 Acknowledgement of Receipt of Licensing Report and return by the close of the business day or upon the next day the child returns to the facility or upon a newly enrolled child within the next 12 months and place the LIC 9224 in each child's file.

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 197494080
VISIT DATE: 12/20/2019
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During this inspection, LPA received declaration from the Licensee, stating Adult #1 will not work or be present in facility until a criminal record exemption is requested and granted. A copy of this declaration has been signed, dated and will be placed in the office physical file.

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment

An exit interview was conducted, and a copy of this report (LIC 809)(LIC 809-D), Civil Penalty Assessment (LIC 421 BG), Advisory Notes- Technical Violation (LIC 9102TV) along with appeal rights were given to Licensee, Jennifer Amador, whose signature confirms today's inspection and report.


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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 197494080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2019
Section Cited

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102370 Criminal Record Clearance
d) All individuals subject to a criminal record review... prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption...required by Department or
This requirement is not met as evidenced by:
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Based on observation, record review and interview, Adult #1 was present at the facility. Although Adult #1 has obtained livescan, Adult #1, has not requested a criminal record exemption nor has received criminal record clearance; which poses an immediate risk to the health, safety and/or personal rights to the children in care.
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Licensee advised Adult #1 could no longer be present at facility during inspection. Adult #1 left facility while LPA was conducting inspection.

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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: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2019
LIC809 (FAS) - (06/04)
Page: 7 of 7