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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494635
Report Date: 10/28/2021
Date Signed: 10/28/2021 05:16:43 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:JERRY FAMILY CHILD CAREFACILITY NUMBER:
197494635
ADMINISTRATOR:JERRY, TIFFANY L.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 256-9634
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY:14CENSUS: 7DATE:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Tiffany JerryTIME COMPLETED:
05:25 PM
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On 10/28/2021 at 1:45 pm Licensing Program Analyst (LPA), Deborah Lowe conducted an unannounced Annual Required Inspection and was met by Licensee, Tiffany Jerry. Also present was Staff #2 (S2). Days and hours of operation are Monday – Friday 7:00 am – 6:00 pm.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the kitchen, bathroom, living room and two bedrooms are used for providing care and are accessible to children. Licensee stated one bedroom is off-limits but not made inaccessible. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items were observed to be inaccessible.

There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, 3 smoke detectors, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818) 514-6063.

There is currently 1 infant in care. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. LPA did not observe Infants sleeping during visit. Licensee stated Infants up to 12 months of age are placed on their backs for sleeping.

SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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: JERRY FAMILY CHILD CARE
FACILITY NUMBER: 197494635
VISIT DATE: 10/28/2021
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Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 08/24/2020. Licensee’s pediatric CPR/First Aid expires on 06/24/2022. A review of records indicates that all employees and/or volunteers do not have immunization records on file for influenza, pertussis and measles.

All adults who reside or work in the home were verified to have criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services.



LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.


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
SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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: JERRY FAMILY CHILD CARE
FACILITY NUMBER: 197494635
VISIT DATE: 10/28/2021
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Safe Sleep

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: H&S 1596.8662(b)(1) and 1597.622(a)(1) (see next page, 809 D). Technical Violations were provided for 1596.8662(C) and 1597.622(C) Licensee was provided a copy of appeal rights.

Notice of Site Visit

A notice of site visit was given and must remain posted for 30 days.

Exit Interview

Exit interview conducted and report was reviewed with the Tiffany Jerry.

SUPERVISOR'S NAME: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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: JERRY FAMILY CHILD CARE
FACILITY NUMBER: 197494635
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with Licensee and record review, the licensee did not comply with the section cited above in 1 of 2 Mandated Reporter Training verifications were not completed by staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
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Staff #2 will complete Mandated Reporter Training and Licensee will send Mandated Reporter Training verification to LPA Lowe via email on or before 11/05/2021.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with Licensee and record review, the licensee did not comply with the section cited above in 2 out of 2 staff without proof of they have been immunized against influenza, pertussis, and measles which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
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 Licensee will provide proof of Licensee's MMR vaccine or titer test by 11/05/2021. Licensee will provide LPA with proof of S2 immunization record with DTap, MMR, and Flu by 11/01/2021.
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: Karren StarksTELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah LoweTELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021
LIC809 (FAS) - (06/04)
Page: 6 of 7