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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494269
Report Date: 11/16/2021
Date Signed: 11/16/2021 10:55:36 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:BOOKER FAMILY CHILD CAREFACILITY NUMBER:
197494269
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
11/16/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Tamika BookerTIME COMPLETED:
11:15 AM
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On 11/16/2021 at 10:15 AM , Licensing Program Analyst (LPA) Stella Gutierrez conducted a case management visit to the family child care home for the purpose of an increase in capacity. The licensee is applying for a large family child care home. Upon arrival, LPA met with the Licensee, Tamika Booker. LPA confirmed that all adults living in the home have obtained a criminal record clearance and are associated to Booker Family Child Care. Fire clearance granted and land lord consent received prior to inspection.

The facility is a 3 bedroom, 2 bathroom home that consists of living room, dining room, family room, kitchen, Laundry room front yard, back yard , and detached garage. . The On-limits areas are: Main care is provided in the Family Room and infant sleeping room provided in bedroom #3. Children will use bathroom #2 located adjacent to bedroom #1 and #2. The off-limits areas are: Living room, Kitchen, laundry room, dining room, bedroom #1 and #2 and bathroom #1. The detached garage, that is used only for storage.
There is one infant that is provided care at the facility, but not present during today's inspection.
Licensee states there are no weapons/firearms in the home, and none observed during today's inspection. LPA, did not observe any bodies of water present at the facility.

.The following was discussed with the licensee:

The licensee was informed to have a qualified assistant when the capacity exceeds 8 children. The assistant must be at least 14 years of age, but can not be left alone with the children in care. If the assistant is 18 years of age and older, the assistant must have current Adult/Infant & Pediatric First Aid certificates if left alone with children while the licensee is out of the home. Each assistant must also have TB clearance, valid criminal record clearance and be associated to the facility license.

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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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: BOOKER FAMILY CHILD CARE
FACILITY NUMBER: 197494269
VISIT DATE: 11/16/2021
NARRATIVE
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Licensee was provided a Self-Assessment guide to follow in response to COVID-19 and was also informed that during today’s inspection that Licensing Program Analyst, Gutierrez provided Technical Assistance in response to reducing the spread of COVID-19. Applicant was informed to follow CDC guidelines and stay up to date with the Provider Information Notices while using best practices during the COVID-19 Pandemic.

Fire extinguisher (2A-10-BC) is located main care area (Family room). Applicant has operable dual Smoke Detectors / Carbon Monoxides located in main care. An accessible First Aid Kit equipped with, cleansing pads healing ointment, bandages, gauze, and a digital thermometer in main care area.

Facility Administration: Licensee completed training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. Pediatric A certificate of completion of a course or courses in preventive health practices as defined in s subdivision (a) or certified copies of transcripts that identify the number of hours and the specific course or courses taken for training. (8 hours required) Preventative Health and Safety practices including lead prevention poisoning and childhood nutrition are completed and placed in facility file.

Pediatric First Aid and CPR expires 09/21/2023 for the applicant.


Licensee stated, that there are no bodies of water on the premises. This includes any fountains, hot tubs, spas, fish ponds. There are no firearms and ammunition kept on the premises. Firearms are kept separate than the ammunition in an accessible area in the facility.

Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. 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 analyst of any person who will be visiting regularly or for longer than one week.
· As discussed Licensee was reminded In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.


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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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: BOOKER FAMILY CHILD CARE
FACILITY NUMBER: 197494269
VISIT DATE: 11/16/2021
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·Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. The family day care home shall maintain documentation of the required immunization's or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the family day care home.
·A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.
·Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated. (If paying by check please make sure to write facility number on check to ensure that payment is applied to your facility number)
· The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced.
·Changes should be reported the to the Department as soon as they occur such as construction and remodeling.

Telephone number changes and/or if you move from home
·Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Fire and safety drills must be performed every six months and documented for review by the Department. (Child care Fire Drill log provided to applicant)
·There is an effective 24/7 ban on smoking tobacco in a home that is licensed as a family day care home, and in those areas of the family day care home where children are present.

Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

·Saucer chairs, bouncers, walkers, or any similar items are prohibited. (Flyer example of what these items may look like given to applicant today)
·All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation. Page 3 of 6

SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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: BOOKER FAMILY CHILD CARE
FACILITY NUMBER: 197494269
VISIT DATE: 11/16/2021
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Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are required to be posted.
·LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov (Applicant was enrolled to receive updates during today's inspection. )

The applicant 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 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: childcareadvocatesprogram@dss.ca.gov
(Child Care Advocate Program Flyer provided.

AB 1207: Mandated Reporter Training (Health and Safety Code 1596.8662 )-Beginning on January 1, 2018, this law 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. Followed by the general training module, the Child Care Providers module is a three hour training that includes eight sections. Mandated Reporter Training completed on 02/18/2021 (AB 1207 printout and Reporting Child Abuse and Neglect flyer provided to Applicant) and provided in facility file.

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


Incidental Medical Services (IMS) policy was discussed 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 IMS Plan of operation in facility file.

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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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: BOOKER FAMILY CHILD CARE
FACILITY NUMBER: 197494269
VISIT DATE: 11/16/2021
NARRATIVE
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Infant safe sleep consultation provided today.

Safe sleep for your baby pamphlet and what does safe sleep look like wall flyer will be provided
LPA discussed safe sleep for infants with applicant: Infants must be placed on their backs and must be physically checked every 15 minutes to gauge temperature and ensure they are breathing. Provider must keep a 15-minute check log of any infant she provides care for at the facility. Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.



Licensee was informed to refer to safe sleep regulations 102425 INFANT SAFE SLEEP for guidance when caring for infants at the Booker FAMILY CHILD CARE. LPA provided a copy of the safe sleep regulations to Licensee. Licensee stated that she understands safe sleep for infants and will use best practices to ensure the safety of the infants cared for at the Booker FAMILY CHILD CARE. Licensing Program Analyst, Gutierrez was open for any questions or concerns at 10:42 AM. regarding the safe sleep regulation and best practices.

SIDS & SHAKEN BABY SYNDROME INFORMATION LPA discussed flyer and was provided to applicant on.(Never Shake a Baby).

FORMS TO BE POSTED LPA, Gutierrez observed postings in main care area today.
· LIC203 Facility License
· LIC 610A Emergency Disaster Plan (Recommended-Not required)
· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster
COVID-19 related flyers and best practices Page 5 of 6
SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 6 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: BOOKER FAMILY CHILD CARE
FACILITY NUMBER: 197494269
VISIT DATE: 11/16/2021
NARRATIVE
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 Children’s records requirements:
· LIC 700 Identification and Emergency Information
· LIC 627 Consent for Emergency Medical Treatment
· LIC 282 Affidavit Regarding Liability Insurance
· LIC 9150 Parent Notification Additional Children in Care
· Immunization record
· PUB 72- Family Child Care Consumer Guide
· LIC 995A Notification of Parent’s Rights
-CDPH PUB 286 (Immunization Blue Card)

FACILITY RECORDS:


· LIC 624B Unusual Incident/Injury Report
· LIC 9040 Child Care Facility Roster
· LIC 9052 Employee Rights,
· LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
· LIC 9149 Landlord Consent Form, if you plan to care for more than 6 children for a Small and 14 children for a large.
· LIC 9151 Property Owner/Landlord Notification Form
· Proof of current pediatric CPR and First Aid Certificates
· Copy of your deed or lease/rental agreement
· Documentation of Fire and Disaster drill

Licensee was made reminded that it is the licensee’s, as well as anyone who assists in providing care responsibility to know the regulations. Applicant was advised on how to access quarterly reports, forms, and regulations for Child Care online at www.ccld.ca.gov. Applicant was also encouraged to read the Child Care quarterly updates every season as they come out to stay informed of any changes or updates to statutes and regulations. Licensee currently receives quarterly updates

An exit interview was conducted, and a copy of this report was provided to the Licensee. Final decision of License for an increase of capacity will be determined upon final file review and will be determined on 11/22/2021 before 5:00PM.

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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6