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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494704
Report Date: 03/08/2021
Date Signed: 03/08/2021 01:38:20 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:HAYES FAMILY CHILD CAREFACILITY NUMBER:
197494704
ADMINISTRATOR:HAYES, ERNESTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 780-0885
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY:14CENSUS: 0DATE:
03/08/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Ernestine HayesTIME COMPLETED:
01:45 PM
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On 03/08/2021 at 10:30 AM Licensing Program Analysts (LPA) Stella Gutierrez conducted an announced change of location pre-licensing tele inspection via FaceTime with Ernestine Hayes. Applicant was provided the Family Child Care Home self-certification check list prior to inspection and completed prior to inspection. Applicant guided LPA on a tour of the home inside and out via FaceTime due to social distancing in response of COVID-19. Applicant was informed that we are going to tour the home for a pre-licensing requirement per title 22 regulations and health and safety standard code requirements. Days of operation are Monday-Sunday 24 Hours with all major holidays closed. Applicant applied for a capacity of 14. Prior License located at 3308 W. 81ST ST. Inglewood CA 90305 license number #197418770 Applicant stated that she will be providing care for ages infant to school age and if there are any changes to her plan of operation that she will contact CLLD prior to doing so to seek guidance.

Applicant 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 will provide Technical Assistance in response to reducing the spread of COVID-19. Applicant was provided the following COVID-19 resources to refer to when in operation:

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN_20-02-CCP.pdf

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN_20-04-CCP.pdf

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN%2020-19-CCP.pdf

https://www.cdss.ca.gov/Portals/9/CCLD/PINs/2020/CCP/PIN-20-11-CCP.pdf

https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf

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

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
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 9
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 197494704
VISIT DATE: 03/08/2021
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Areas identified in the sketch and inspected during today’s visit:

This is a single-story dwelling that consist of a living room, dining room, kitchen, 3 bedrooms, 2 bathrooms, laundry room, detached den and detached garage. Front yard (not fenced) with courtyard behind gate. Side door located off Victoria Ave is where children will enter the facility. Back yard (fenced in) consists of play area, one side yard sliding glass doors to den area, 3 stairs to the back door to enter home and door to enter detached garage.

Upon entering LPA, Gutierrez did not observe posters that discuss symptoms of COVID-19 and procedures to follow during the pandemic before entering the facility. Applicant was emailed these items prior to license and self assessment with posters. Applicant stated that she will later post these items. LPA observed a touch free digital thermometer, hand sanitizer and several pens located at the entrance of the facility. Applicant was reminded to take daily temperatures and have children wash their hands when arriving to the facility.

On Limits:

Main care room, Den which is a separate building than the home, Living room, Kitchen, Dining room Bathroom # 2. When entering the facility from the side of the house, LPA observed a play yard which is on limits. To the right of play yard is a den area where the main recreation activities will take place. When entering the LPA observed the parents sign in and sign out log, hand sanitizer, several pens and a touch free digital thermometer for taking daily temperatures. Fire extinguisher located on shelf that was purchase on 02/12/2021, First Aid kit located on wall equipped with, cleansing pads healing ointment, bandages, gauze, and a touch free digital thermometer that is kept in main play room den and inside home. , an operable dual smoke alarm/carbon monoxide detector, cubbies, toys, books, flat screen television mounded on wall that will be used for movie time, table chairs and several other learning materials that are age appropriate. Bathroom #2 located when entering back door of the home on right side. Bathroom was inspected: LPA observed and adequate supply of soap and poster guidance of effective hand washing procedures during COVID-19 provided next to sink. 1 operable toilet, sink and no immediate or potential hazards. Laundry area located next to bathroom. Any detergents or liquid are kept in the Applicants bedroom

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

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 9
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 197494704
VISIT DATE: 03/08/2021
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to make inaccessible to the children. Kitchen is located next to laundry area where LPA observed cabinets with latches and sharp objects kept in a top tier shelf. There is a breakfast nook in the kitchen area that the children will use for snack and meals. Dining room is located next to kitchen where there is more table seating, if needed, for the children in care. Living room across from dining area was observed. LPA observed sofas and shelves in this area. Applicant stated that this is where the children will be provided with nap time. 3 cots and 1 crib were observed during today's visit. LPA, Gutierrez observed an operable smoke alarm/ carbon monoxide in the hall and kitchen area. Applicant did not observe a fire extinguisher in the home where meal and nap time will be provided. A second fully equipped First Aid located in living room shelf.

On limits exterior:

Play yard located when entering the facility will be where the children will be provided with outside time. Play yard is with concrete. LPA observed bikes, basketball hoop, hula hoops, scooters. LPA advised Applicant to reduce any fast paced running in this area due the premises being concrete to avoid any potential accidents when the children are playing outside. LPA, Gutierrez observed hanging cords / cable cords in the on limits outside play area. This could pose and immediate risk to the children in care. LPA advised applicant that these cords will have to be removed or made inaccessible to the children in care.

Off limits:

Bedroom #1 , #2, #3 , bathroom #1 and detached garage. Hall door is kept shut to make these rooms inaccessible to the children. LPA, Gutierrez observed no immediate or potential hazards in the off limits areas during today's inspection. Applicant stated that the door will be kept closed when children are in care. Side yard where trash cans are and exit to front yard of home. Front yard is off limits and side yard will be kept off limits by supervision. Detached garage is accessible through a door from play yard. LPA inspected the garage to be a storage room. Applicant stated that the garage will be inaccessible to the children by door staying locked when children are in care.

Facility Administration: Applicant 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



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

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 197494704
VISIT DATE: 03/08/2021
NARRATIVE
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courses taken for training. (8 hours required) Preventative Health and Safety practices completed and placed in facility file.

Pediatric First Aid and CPR expires 09/28/2022 for the applicant, immunization's are on file pending influenza or influenza waiver on file.

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

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 4 of 9
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 197494704
VISIT DATE: 03/08/2021
NARRATIVE
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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.
·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 currently receives quarterly updates)

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 given to applicant via postage mail)

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 (AB 1207 printout and Reporting Child Abuse and Neglect flyer provided to Applicant) and provided 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: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 5 of 9
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 197494704
VISIT DATE: 03/08/2021
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Applicant will not be providing IMS incidental medical services at this time. However, if she decides to do so she will inform CCLD-Child care Licensing and submit a plan prior to doing so.

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

Infant safe sleep consultation provided today-



Safe Sleep Links:
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

Safe sleep for your baby pamphlet and what does safe sleep look like wall flyer provided to applicant. Safe Sleep new flyer (5/23/2019) also given to applicant via postage mail.



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. It was recommended by LPA to 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.

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

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 6 of 9
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 197494704
VISIT DATE: 03/08/2021
NARRATIVE
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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.
Applicant was informed to refer to safe sleep regulations 102425 INFANT SAFE SLEEP for guidance when caring for infants at the HAYES FAMILY CHILD CARE. LPA provided a copy via email of the safe sleep regulations to Applicant. Applicant stated that she understands safe sleep for infants and will use best practices to ensure the safety of the infants cared for at the HAYES FAMILY CHILD CARE. Licensing Program Analyst, Gutierrez was open for any questions or concerns regarding the safe sleep regulation and best practices. Applicant resumed with no questions or concerns at this time. 03/08/2021 at 11:12 AM.

SIDS & SHAKEN BABY SYNDROME INFORMATION LPA discussed flyer mailed to applicant via postage mail today (Never Shake a Baby) Applicant reviewed flyer and understands the preventive practices of shaken baby syndrome and abusive head trauma.

FORMS TO BE POSTED
· LIC203 Facility License
· LIC 610A Emergency Disaster Plan
· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster
COVID-19 related flyers and best practices

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)
Page 7 of 9
SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 7 of 9
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 197494704
VISIT DATE: 03/08/2021
NARRATIVE
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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
· 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 drills
· Proof of immunization's against pertussis (TDAP), measles (MMR), and influenza
· Mandated Reporter certificate – www.mandatedreporterca.com – renewed every two years.

Other documents given to Applicant: California Car Seat Law changes effective January 1, 2017, Ratio flyers for both small and large Family Child Care Homes, California Childcare Health Program Healthy Beverages in Child Care, Prohibited Items in child care family homes, Effects of Lead Exposure (CDSS Flyer), Child Care Advocate Program support sheet and “Keep me safe” printout.

A packet that includes the documents listed above were provided and discussed.

Applicant 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. Applicant currently receives quarterly updates from CCLD/Childcare. Applicant is registered to receive quarterly updates.



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

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 197494704
VISIT DATE: 03/08/2021
NARRATIVE
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The following items were discussed with the applicant to complete the application process:


1. Picture of new Fire Extinguisher with purchase receipt located in home via email to LPA.
2. Picture of cable cords made inaccessible to the children's outside play area.
3. Mail previous license with letter to LPA via postage mail or bring in the office.


An exit interview was conducted, and a copy of this report was provided to the Applicant, Ernestine Hayes. Final decision of License issuance will be determined by the department unit Licensing Program Manager.






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

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 9 of 9