197494425-11-22-2019-30-CC-LRIS-BJ5RNW-20191121121057

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494425
Report Date: 11/21/2019
Date Signed: 11/22/2019 09:59:33 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:	AMBREEN FAMILY CHILD CARE		FACILITY NUMBER:	197494425
ADMINISTRATOR:	AMBREEN, AYESHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 687-2408
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	14	CENSUS: 0	DATE:	11/21/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee Ayesha Ambreen		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On November 21st^th at 10:00 am an announced visit was made for the purpose of conducting a Pre-licensing Inspection. Licensing Program Analysts (LPAs) Stella Gutierrez and Lisa Rios met with the licensee/applicant and toured the home inside and out inspecting all area on the application sketch. There are 0 children residing in the home. The Home is a two story house and set up as follows: Downstairs: Dining Room which will be used to provide service and care. There is a camera here that requires a waiver. Family Room which will be used to provide service and care. Living Room which will be off limits to the children except to pass through to the backyard. Kitchen which will be off limits to children in care. Under sink cabinet has a child proof lock. There is also a dining room table and chairs in the kitchen area. Off the entrance way is a 3/4 bathroom which will be used by the children. The bathroom has a child lock on the under sink cabinet and is need of a children's potty seat for children who will be potty trained. Also off the entranceway is a single car garage with a lock from the inside which is off limits to the children in care. Upstairs: Bedroom #1 -is at the top of the stairs to the right and sleeps licensee’s 12 year old daughter. Bedroom #2 -is located to the left of the stairs and sleeps licensee's 10 year old son. Bedroom #3 -is located to the left of the stairs and sleeps licensee's infant son. Bedroom #4 is a master bedroom which has an attached bathroom. Licensee reported there are no fire arms or weapons in the home. This is where the licensee and her husband sleep.

SUPERVISOR'S NAME: Jennie Ferreira	TELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

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: AMBREEN FAMILY CHILD CARE	FACILITY NUMBER: 197494425
	VISIT DATE: 11/21/2019

NARRATIVE

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During the walk through of the facility LPA’s Gutierrez and Rios found that the facility is clean, safe, sanitary, and in good repair. Stairway has gates mounted at the bottom and upstairs is all off limits.. Disinfectants/poisons and other hazardous items are inaccessible, they are kept locked in cabinets. The home has one working carbon monoxide detector at the top of the stairs. Licensee was told that she would need a carbon monoxide detector on the downstairs level along with smoke detector. 2 Fire extinguishers 2-A10BC were observed in the home, each needs to show it was serviced with a date and/or a receipt of when purchased. The home is missing a complete first aid kit including thermometer. Toys and play areas are age appropriate. LPA's observed 4 cots for napping equipment.
All necessary postings are missing from the home: Parents Rights, Emergency Disaster Plan
There are no excluded persons on premises and all adults working in the home have Criminal Clearances.
Licensee has been reminded to report children injuries requiring medical treatment and other special incidents.

Incidental Medical Services (IMS) if provided, with a plan of operation of file. Licensee has current First Aid/CPR and Mandated Reporter Training, along with proof of immunization.
The following was discussed:

Assembly Bill (AB) 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 (SB) 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.

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

SUPERVISOR'S NAME: Jennie Ferreira	TELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

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: AMBREEN FAMILY CHILD CARE	FACILITY NUMBER: 197494425
	VISIT DATE: 11/21/2019

NARRATIVE

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Update on Incidental Medical Services: Facilities that provide Incidental Medical Services (IMS) must identify those services in their facility’s Plan of Operation and submit an updated Plan of Operation 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.

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. Failure to obtain a criminal record background check clearance prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

Licensee was made aware 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

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. LPA provide brochures will information regarding SIDS and never shake a baby to prevent the shaken baby syndrome.

SUPERVISOR'S NAME: Jennie Ferreira	TELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

LIC809 (FAS) - (06/04)

Page: 7 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: AMBREEN FAMILY CHILD CARE	FACILITY NUMBER: 197494425
	VISIT DATE: 11/21/2019

NARRATIVE

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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 and immunization. Licensee was informed, Absence of Supervision: including, but not limited to, a child left unattended, a child left alone with a person under 18 years of age, and lack of supervision resulting in a child wandering away. (HSC 1597.58(c)(2)). Regulation(s): 102417(k)(1) Children shall not be left in parked vehicles. Civil penalty applies when a child is left unattended in a parked vehicle.

The following forms were given to the Licensee in the form of a packet:

At your home inspection, your Licensing Program Analyst will also review all the required forms and information that

you must keep on file in your home. Please do not submit any of these documents with the application.
However, have them readily available at the time of your pre-licensing visit so your Licensing Program Analyst can
discuss them with you. Records must be kept for three years.
CHILDREN'S FORMS/RECORDS
Children's files must contain the following documents/information:
● Parent Notification, Additional Children in Care (LIC 9150), if you plan to care for more than 6 children
for a Small Family Child Care Home, or more than 12 for a Large Family Child Care Home.
● Affidavit Regarding Liability Insurance (LIC 282) - This form is required to be signed by each parent
of a child in care if you do not have either liability insurance or a bond.
● Consent for Medical Treatment (LIC 627) - This document gives you permission by the parent to seek
emergency medical or dental care for their child if needed.
● Consent/Verification for Nebulizer Care (LIC 9166) - Before a child care licensee or staff person can
administer inhaled medication to a child in care, this form must be completed and filed in the child's
record and in the personnel file. A separate form must be filled out for each person who
administers inhaled medication to the child.
● Identification and Emergency Information (LIC 700) - This form must be kept for each child in care
and identifies whom to call in an emergency.
● Notification of Parents' Rights (LIC 995A) - This form must be given to each parent at the time a child
is accepted for care, along with the LIC 995E.
● Caregiver Background Check Process (LIC 995E) - This form must be given to each parent at the
time a child is accepted for care, along with the LIC 995A.
● Family Child Care Consumer Awareness Information (LIC 9212) - This form must be given to
the parents of each child in care.
● California School Immunization Record (blue card) (PM 286) - For every infant, toddler, or preschool
age child admitted into a Family Child Care Home, the provider must maintain current immunization
records on the PM 286. It can be downloaded from the following website:
http://www.dhs.ca.gov/publications/forms/immunization.htm but must be printed on blue paper only.
● Acknowledgement of Receipt of Licensing Reports (LIC 9224), if applicable.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY LIC 311D (3/07) PAGE 1 OF 2 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

SUPERVISOR'S NAME: Jennie Ferreira	TELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

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: AMBREEN FAMILY CHILD CARE	FACILITY NUMBER: 197494425
	VISIT DATE: 11/21/2019

NARRATIVE

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CHILDREN'S FORMS/RECORDS
Children's files must contain the following documents/information:
● Parent Notification, Additional Children in Care (LIC 9150), if you plan to care for more than 6 children
for a Small Family Child Care Home, or more than 12 for a Large Family Child Care Home.
● Affidavit Regarding Liability Insurance (LIC 282) - This form is required to be signed by each parent
of a child in care if you do not have either liability insurance or a bond.
● Consent for Medical Treatment (LIC 627) - This document gives you permission by the parent to seek
emergency medical or dental care for their child if needed.
● Consent/Verification for Nebulizer Care (LIC 9166) - Before a child care licensee or staff person can
administer inhaled medication to a child in care, this form must be completed and filed in the child's
record and in the personnel file. A separate form must be filled out for each person who
administers inhaled medication to the child.
● Identification and Emergency Information (LIC 700) - This form must be kept for each child in care
and identifies whom to call in an emergency.
● Notification of Parents' Rights (LIC 995A) - This form must be given to each parent at the time a child
is accepted for care, along with the LIC 995E.
● Caregiver Background Check Process (LIC 995E) - This form must be given to each parent at the
time a child is accepted for care, along with the LIC 995A.
● Family Child Care Consumer Awareness Information (LIC 9212) - This form must be given to
the parents of each child in care.
● California School Immunization Record (blue card) (PM 286) - For every infant, toddler, or preschool
age child admitted into a Family Child Care Home, the provider must maintain current immunization
records on the PM 286. It can be downloaded from the following website:
http://www.dhs.ca.gov/publications/forms/immunization.htm but must be printed on blue paper only.
● Acknowledgement of Receipt of Licensing Reports (LIC 9224), if applicable.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY LIC 311D (3/07) PAGE 1 OF 2 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

SUPERVISOR'S NAME: Jennie Ferreira	TELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

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: AMBREEN FAMILY CHILD CARE	FACILITY NUMBER: 197494425
	VISIT DATE: 11/21/2019

NARRATIVE

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Facility files must contain the following documents/information:
● Personnel Records as required in Title 22, Division 12, Chapter 3, Section 102416.1, including but
not limited to, proof of current pediatric first aid, CPR and preventive health practices certificate and
criminal record information.
● Unusual Incident/Injury Report (LIC 624B) - You must use this form and submit it to your local
licensing office when reporting any incidents or injuries occurring during day care hours.
● Child Care Facility Roster (LIC 9040) - It is required that each child care facility maintain a current
roster of children who are provided care.
● Notice of Employee Rights (LIC 9052) - This form must be filled out by all employees working in the
Family Child Care Home.
● Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108) -This form is
the Child Care Custodian's acknowledgement of the requirement to report suspected child abuse.
● Property Owner/Landlord Consent Form (LIC 9149), if you plan to care for more than 6 children for a
Small Family Child Care Home or more than 12 for a Large Family Child Care Home.
● Property Owner/Landlord Notification Form (LIC 9151).
● A copy of your deed or lease/rental agreement.
INFORMATION TO BE POSTED IN YOUR FAMILY CHILD CARE HOME
You are required by law to post the following in your home:
● Emergency Disaster Plan (LIC 610A) - This must be posted in your home next to the telephone and
the Earthquake Preparedness Checklist (LIC 9148), must be attached to the LIC 610A and available
to the public.
● Notification of Parents' Rights Poster (PUB 394) - This poster must be placed in an area of the home
where all parents can see it
● Facility License, (LIC 203)-Your Family Child Care Home License must be posted in an area of the
home where it can be easily seen.
● Notice of Site Visit (LIC 9213) must remain posted for 30 days (during the hours that children are in
care) after each site visit by a licensing representative.
● Any licensing report documenting a type “A” citation must be posted for 30 days during the hours that children
are in care.
● Any licensing report or other document verifying compliance or non-compliance with the Department’s order
to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

SUPERVISOR'S NAME: Jennie Ferreira	TELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

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: AMBREEN FAMILY CHILD CARE	FACILITY NUMBER: 197494425
	VISIT DATE: 11/21/2019

NARRATIVE

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Flyers given to licensee:

· Never shake a baby

· Keep Me Safe!

· Car Seat and Booster Seat Laws

· Healthy Beverages in Child Care

· Prohibited Items in Family Child Care Homes

Exit interview conducted. Copy of Report was given to licensee.

SUPERVISOR'S NAME: Jennie Ferreira	TELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

LIC809 (FAS) - (06/04)

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