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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494863
Report Date: 11/22/2021
Date Signed: 11/22/2021 01:20:00 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:HAGGERSTROM FAMILY CHILD CAREFACILITY NUMBER:
197494863
ADMINISTRATOR:CECILIA GAGGERSTROMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 633-3375
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:14CENSUS: 0DATE:
11/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cecilia Haggerstrom, LicenseeTIME COMPLETED:
11:30 AM
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On 11/22/2021 at 10:00 am, Licensing Program Analyst (LPA) Sabrina Martinez conducted an announced Pre-Licensing inspection. The purpose of the inspection was to ensure that health, safety and personal rights, as required by Title 22 Regulations governing California Family Child Care Homes, will be met by the applicant, Cecilia Haggerstrom.

This is an application for a relocation and an application for a Large Family Child Care Home. The facility has a granted fire clearance from the Santa Monica Fire Department. The facility is located at 2930 Delaware Ave., Santa Monica, CA 90404. Licensee was previously licensed as a Small Family Child Care Home for Facility 197494435.

LPA Martinez met with applicant, Cecilia Haggerstrom, and was guided on a tour of the indoor and outdoor of the home. LPA did not observe any children in care during this inspection. Per applicant, the residents in the home include applicant and her son. LPA observed that Licensee has a criminal record clearance and is associated to the facility.

The home is a one story dwelling with four bedrooms, three bathrooms, living room, dining room, play room, kitchen, front and back yard, and detached garage. There is a fireplace in the living room. Applicant was informed that the fireplace must be screened.

The primary childcare area of the home is in the play room. Safe toys and play equipment are observed. The children will also utilize the bathroom next to the play room. LPA inspected the bathroom and did not observe any medications, toxins or cleaning compounds that would pose a risk to children in care. Day care children will nap in bedroom #2. Outdoor play area is conducted in the back yard which was fully fenced. LPA did not observe any debris or hazards that would pose a risk to children in care.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863
VISIT DATE: 11/22/2021
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The off-limit areas of the home are the following; master bedroom, bedroom #1 and bedroom #3, bathroom #1, bathroom #2, living room, dining room, kitchen and front yard. LPA observed child safety gates making of-limit spaces inaccessible to children in care.

The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Hazardous materials in the kitchen and bathroom are inaccessible to children. All poisons are locked. According to the applicant, there are no weapons or firearms at the home; None were observed by LPA. No pets were observed in the home. Applicant was reminded to ensure that pets are off limits to day care children during day care hours.

LPA Martinez observed the following:
*Fire safety requirements: Fully charged fire extinguisher (Classification: 3A40BC), smoke and carbon monoxide detectors present and operable
*Applicant is currently certified in Pediatric CPR/First Aid and has completed the preventive health and safety training, childhood nutrition training and lead poisoning prevention training
*Toys and equipment are observed and in good repair
* The home is equipped with a first-aid kit: cleansing pads, band aid, bandages, gauze, and a digital thermometer
*All toxins and detergents are in locked/latched cabinets
*Electrical outlets have safety covers installed
*Applicant states that there are no guns/weapons in the home
*LPA did not observe firearms and other dangerous weapons during the inspection
*LPA Martinez did not observe bodies of water

The following items were thoroughly discussed with the applicant:
*Requirements for fire drills, earthquake drills, and documentation for both
*The necessity of earthquake safety and drills twice a year
*The role and responsibilities of being a mandated reporter
*Mandatory Forms for the children’s files and provider’s files
*Applicant was referred to LIC 311D: Records to be Maintained at The Facility - Family Child Care Home.
*Applicant was made aware that it is their responsibility, as well as anyone who assists in providing care,
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863
VISIT DATE: 11/22/2021
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, to know Title 22 Regulations.
*The applicant was advised on how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov
*The applicant was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must have the facility’s phone number at all times. If the phone number has changed, licensing must be notified.
*Regulation prohibits the smoking of tobacco on the premises
*State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category
* All infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome)
*Applicant was informed that all provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. Safe to Sleep Campaign:
https://safetosleep.nichd.nih.gov/materials19-02 CCP Safe Sleep Awareness Campaign
*Only children eating may be in highchairs and that car seats are utilized only for transportation.
*Requirements for fingerprint clearances and associations are discussed with the applicant. The applicant was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day up to $500.00 (5 days) for the 1st offense and up to $3000.00 for the 2nd offense within a 12-month period. The applicant may find additional information and forms on the Department’s website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507.

*LPA Martinez informed applicant how to obtain Quarterly Updates. Applicant was 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. 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 childcare 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
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863
VISIT DATE: 11/22/2021
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*The applicant was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and licensing within the time frame specified by the regulation. *The "Notification of Parent's Rights" (PUB394) poster must be posted in an area accessible to parents. *The applicants were advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days.
*LPA discussed AB633 and informed applicant that upon receipt of a Type A deficiency, the applicants shall post and provide copies of this licensing report (LIC 809 or LIC 9099 and copy of LIC 9224 to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed.
*Complaints shall be reported by applicant/licensee and/or parents to the complaint hotline at (844) 538-8766 and for general information and incident reporting; contact their local childcare office.

*Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a childcare facility or family day care if he or she has not been immunized against influenza, pertussis and measles.

*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. Website: www.mandatedreporterca.com Applicants were reminded of their responsibility to report suspected child abuse.

*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 Carrying out medical orders when the child’s physician has determined that a layperson can be trained and safely carry out the orders. 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

SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: HAGGERSTROM FAMILY CHILD CARE
FACILITY NUMBER: 197494863
VISIT DATE: 11/22/2021
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 *New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment. *Applicant was informed of the following items that must be posted in visual site once licensed: (1) License (2) Emergency Disaster Plan (3) Children’s Roster (4) Parents Rights Poster PUB 394, Personal Rights LIC 613-A Recent regulatory changes were discussed.

Below are forms, found at www.ccld.ca.gov, that applicants shall use for record keeping and posting requirements:

LIC 9040 Child Care Facility Roster (Retain for 3 years) most recent must be posted


LIC 9148 Earthquake Preparedness Checklist
LIC 627 Consent for Medical Treatment
LIC 702 Child's Preadmission Health History-Parents Report
LIC 995 Notification of Parent's Rights
PUB 394 Notification of Parent's Rights Poster 12/06 (issued & discussed)
LIC 613-A Personal Rights
LIC 700 Identification and Emergency Information
LIC 282 Affidavit Regarding Liability for Family Child Care Homes
LIC 9224 Acknowledgement of Receipt of Licensing Reports 12/06 (issued & discussed)
Title 22, Division 12 Regulations (access website: http://ccld.ca.gov)


Based upon the inspection, the following requirements have to be completed prior to licensure:

1.) The fireplace in the living room must be screened
2.) Licensee to provide written declaration for the trampoline in the backyard

An exit interview was conducted with the above items discussed and a copy of this report was provided to applicant, Cecilia Haggerstrom.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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