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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494080
Report Date: 11/05/2020
Date Signed: 11/05/2020 04:51:41 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: 10DATE:
11/05/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Jennifer AmadorTIME COMPLETED:
04:59 PM
NARRATIVE
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On 11/05/2020 at 11:12am Licensing Program Analyst (LPA) Laticia Thompson conducted a Case Management inspection Upon arrival LPA was greeted by Jennifer Amador (Licensee).

On 10/31/2020 during an unannounced inspection LPA observed the following deficiencies:

Staff#1 Did not have a criminal record clearance transfer and has not been associated to the facility. Per our conversation licensee stated S#1 has been providing assistance for children in the facility since May of 2020.
Staff#2 Did not have a criminal record clearance, licensee stated S#2 was on an interview LPA observed S#2 alone with children in the backyard area.
Collection of disorganized items lying around in entry of the door way, living room, baby room and dining room areas
Soiled dishes and sharp utensils in sink and on counter top area which were accessible to children.
In the bathroom, LPA observed an unlatched cabinet and bath tub area that contained hazardous material which was accessible to children.
Licensee was unable to provide a roster of children currently enrolled in the facility and children’s files were found to be incomplete.
Large pet (Pit Bull) accessible to children in care and no vaccination information available.
Children and Staff not wearing Personal Protective Equipment (PPE).

The facility is cited three Type A violations. See LIC809-D for details. Each report (documenting a Type A citation) shall remain posted for 30 days along with the Notice of Site Visit (printed out during this inspection).
The facility is cited three Type B violations. (see LIC 809Ds). Each report (documenting a Type B citation)shall remain posted for 30 days along with the Notice of Site Visit (printed out during this inspection).

SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
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 6
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: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2020
Section Cited

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102370 Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.
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This requirement is not met as evidence by
Based on observation and interview the licensse did not ensure a criminal record clearance was obtained for Staff#1 which poses an immediate Health & Safety risk to children in care.
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Licensee must inform the parents/guardians of children in care at the facility and parents /guardians of children newly enrolled within the next 12 months via form LIC-9224 Acknowledgement of Receipt of Licensing Reports. Civil Penalties were assessed.
Type A
10/31/2020
Section Cited

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102370 Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, in a licensed facility:2) Request a transfer of a criminal record clearance as specified in Section 102370(j)
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This requirement is not met as evidence by,
Based on observation, interview and record review the licensse did not request a criminal record clearance transfer clearance for Staff#2 which poses an immediate Health & Safety risk to children in care.
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Licensee must inform the parents/guardians of children in care at the facility and parents /guardians of children newly enrolled within the next 12 months via form LIC-9224 Acknowledgement of Receipt of Licensing Reports. Civil Penalties were assessed.
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: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2020
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: 11/05/2020
NARRATIVE
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On 11/05/2020 based on interviews and observation LPA determined S#2 has been providing assistance for children under care in the facility more than 30 days.

On 11/05/2020 LPA observed a sharp knife in dish rack which was accessible to children. Licensee removed knife from dish rack immediately and placed it in a cabinet above the counter area and secured the cabinet a with a safety latch.

Assembly Bill No. 633
“Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.”
Family child care homes shall post during hours of operation. Each of these reports shall remain posted for 30 days.
The licensee shall keep verification of receipt in each child’s file.
Failure to meet the posting requirements shall result in an immediate $100.00 civil penalty.

Licensee provided LPA with an Original LIC 279 with updated address and phone number.
Licensee provided LPA with LIC 9182, LIC508 and copy CA Id for Beatriz Gaytan

An exit interview was conducted and a copy of this report, Appeal Rights (LIC9058), LIC 9224, LIC 311, LIC 9102, Assembly Bill No. 633, 421B, were provided to the Licensee Jennifer Amador.
SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2020
Section Cited

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102417 Operation of a Family Child Care Home
(b) The home shall be kept clean and orderly

The requirement is not met as evidenced by,
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Based on obervation of soiled dishes in sink and on the counter top. Observation of collection of disorganized items lying around in entry of the door way, living room, baby room and dining room areas, which posses a potential Health, Safety, or Personal Rights Risk to children in care.
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Type B
11/09/2020
Section Cited

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102417 Operation of a Family Child Care Home (g)(7) An emergency information card shall be maintained for each child...include the child's full name, telephone number and location of a parent or other...to be contacted in an emergency... the name and telephone number of the child's physician... parent's authorization for the licensee or... to
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consent to emergency medical care. The requirement is not met as evidenced by,Based on record review children files were found to be incomplete and missing information,which poses an potential Health Safety, risk to 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: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2020
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2020
Section Cited

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102417 Operation of a Family Child Care Home (g) The home shall be free from defects or conditions which might endanger a child.., .(4) Poisons, detergents, cleaning compounds medicines, firearms and other items which could pose a danger if readily available to

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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: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2020
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2020
Section Cited

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102417 Operation of a Family Child Care Home (g)(8)Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841

The requirement is not met as evidenced by,
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Based on observation, interview and record review the licensse was unable to provide a roster of children currently enrolled in the facility, which causes an potential health and safety risk to children under 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: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2020
LIC809 (FAS) - (06/04)
Page: 6 of 6