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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495032
Report Date: 03/10/2022
Date Signed: 03/14/2022 09:25:33 AM


Document Has Been Signed on 03/14/2022 09:25 AM - It Cannot Be Edited

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:MONTEIRO FAMILY CHILD CAREFACILITY NUMBER:
197495032
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: DATE:
03/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Shavon MonteiroTIME COMPLETED:
12:30 PM
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On 3/10/2022 Licensing Program Analyst (LPA) Judy Laureano conducted an announced inspection with applicant, Shavon Monteiro, for the purpose of a pre-licensing inspection of 4161 4th Avenue, Los Angeles, CA 90008. The purpose of this inspection is to ensure the standards for a Family Child Care Home are being met in accordance to California Tittle 22 Regulations and California Health and Safety Codes.

The applicant is applying for a change of location for a small family childcare license with a max capacity of 8. Applicant resides in the home with her 3 minor children. Property owner/landlord consent (LIC 9151) is currently on file. Lease agreement/control of property was received.

Application received is a change of location, applicant was licensed at 513 S. Mariposa Avenue #302, Los Angeles, CA 90020- #198017801.

Per the application, currently, the ages the applicant wishes to provide services for children 2-months to 12 years old with the hours of operation of 24 hours a day Monday through Friday. Applicant will be available for overnight care. Applicant were informed that any changes to ages, hours and days of operation shall be submitted to the department for approval prior to initiation of changes.

The home is a single-family two story home with 3 bedrooms, 2 bathrooms, living room, den, Kitchenette, Kitchen and laundry room. Home has both a front yard and a back yard, back yard is enclosed with a wooden gate. The home does have an attached garage that will be OFF LIMITS to the children in care. Applicant confirmed that the second floor is off limits to the children in care. LPA observed a safety gate at the bottom of the stairs and a safety gate at the top of the stairs.

SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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: MONTEIRO FAMILY CHILD CARE
FACILITY NUMBER: 197495032
VISIT DATE: 03/10/2022
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Parents will access the home through the main entrance.

Entering the home, LPA observed the entry way where parents will arrive and children will complete a wellness check. The parent board was observed to be in the entry way of the home. All necessary posting were observed by LPA. A storage closet across from the main entrance was observed to have extra day care supplies and napping cots.

Entering the living room, LPA observed a safety gate making the main door inaccessible to the children in care. The living room was observed to have a fire place barricaded with a metal gate and a children’s storage unit. Applicant confirmed she will not be using the fire place. A television set was observed to be mounted above the fire place. LPA observed a couch and a child size cubbie with age appropriate toys. LPAs observed children’s size desks, children size tables with soft chairs and a variety of cubbies for children to use. A First Aid Kit was observed by the main door.

Next to living room LPA observed the den area to have 4 pack and plays, a changing table and additional toys for children to use. A safety gate was observed at all entry ways. All electrical outlets were covered.

Next to the den, a safety gate was observed making bedroom 1 and the basement inaccessible to the children in care. LPA observed all door to have a plastic doorknob cover making the areas in accessible.

The bathroom that children will use is located next to bedroom 1. A toilet, sink, cabinets and shower were inspected. All electric outlets were covered and cabinet under the sink was secured with a safety latch. LPA discussed COVID-19 recommendation such as using paper towels and displaying a handwashing sign for children to view.

The kitchenette was observed to be next to the kitchen, one is able to enter the kitchenette through the den and kitchen area. The kitchenette was observed to have 5 high chairs and a water dispenser. All electrical outlets were covered.

Outside the kitchenette you are able to access the kitchen. A safety gate was observed

SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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: MONTEIRO FAMILY CHILD CARE
FACILITY NUMBER: 197495032
VISIT DATE: 03/10/2022
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making the kitchen in accessible. Kitchen cabinets were observed to have safety latches. The stove, refrigerator, sink and counter space area were observed and inspected. Knifes and sharp object were observed to be made inaccessible to the children in care. Applicant confirmed that facility will be providing meals and snacks. LPA discuss food preparation, storage and ensuring a log and information regarding dietary restrictions and allergies are kept up to date. As a COVID precautions, LPAs advised applicants to use disposable paper goods. LPA observed two working fire extinguishers next to the stove. LPA observed applicant test the carbon monoxide and smoke detector.

The kitchen leads you to the laundry room and has been designated off limits. Laundry room was observed to have a side door that leads to the backyard.

The backyard has been designated as the outdoor area that children will use. LPA observed age appropriate toys such as children’s size basketball set and outdoor children’s size plastic slides.

LPA observed the garage that has been designated as OFF LIMITS to the children in care and will remain locked during the hours of operations.

LPA observed the second story to have storage closet, bedroom 2, bathroom 2 and bedroom 3; all designated as off limits to the children in care. LPA observed bedroom 3 to have a door that lead to a patio area. Applicant confirmed all areas in the 2nd floor are off limits.

The following areas are off limits to the children in care:

Second Story: Bedroom 2, Bedroom 3 with the Patio and Bathroom 2
First Floor: Bedroom 1 and Basement

LPA observed all door to have plastic doorknob covers to make the areas inaccessible as well as safety gates in all entry ways of the home.

No corrections were observed during today’s inspections. Exit interview was conducted with applicants Shavon Monteiro. The licensing determination of this application will be reviewed with Licensing Program Manager for final resolution.

SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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: MONTEIRO FAMILY CHILD CARE
FACILITY NUMBER: 197495032
VISIT DATE: 03/10/2022
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The following was discussed with the applicant:
Applicant 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 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

Immunizations: 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. LPA discussed the influenza waiver during the inspection.

Mandated Reporter Training: 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. Licensee was reminded of their responsibility to report suspected child abuse.


Mandatory Forms for the children’s files and provider’s files were discussed. Applicant was referred to LIC 311D: Records To Keep in Your Family Child Care.

FORMS TO BE POSTED


LIC203 Facility License
LIC 610A Emergency Disaster Plan
LIC 9148 Earthquake Preparedness Checklist
PUB394 Notification of Parents Rights Poster
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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: MONTEIRO FAMILY CHILD CARE
FACILITY NUMBER: 197495032
VISIT DATE: 03/10/2022
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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
LIC 9166 Consent/Verification for Nebulizer Care
CDPH 286 (Immunization Blue Card) with Immunization record
PUB 72- Family Child Care Consumer Guide
LIC 995A Notification of Parent’s Rights
LIC 995E Caregiver Background Check Process
LIC 9212 Family Child Care Consumer Awareness Information
PM 286 California School Immunization Record (blue card)-http://www.dhs.ca.gov/publications/forms/immunization.htm
LIC 9224 Acknowledgement of Receipt of Licensing Report, if applicable.
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 for Small or 12 for Large
LIC 9151 Property Owner/Landlord Notification Form
Personnel Records as required in Tittle 22, Division 12, Chapter 3, Section 102416.1, including but not limited to proof of current pediatric CPR and First Aid Certificates, Preventative Health certificate and criminal record information.
Copy of your deed or lease/rental agreement
Documentation of Fire and Disaster drill
Proof of immunization's against pertussis (TDAP), measles (MMR), and influenza
Mandated Reporter certificate – www.mandated reporterca.com – renewed every two years.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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: MONTEIRO FAMILY CHILD CARE
FACILITY NUMBER: 197495032
VISIT DATE: 03/10/2022
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 Licensee was made reminded that it is the licensee’s, as well as anyone who assists in providing care responsibility to know the regulations. Licensee 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 was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family childcare home during the hours of operation.



Applicant was made aware that state law prohibits baby walkers, bouncy seats, exer-saucers and any other items that fall into that category. Applicant was also reminded that only children who are eating may be in highchairs and that car seats are utilized only for transportation.

LPA discussed the safe sleep regulations with applicant [or facility representative] 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 applicant [facility representative] 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.

This facility plans to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Home. 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: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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: MONTEIRO FAMILY CHILD CARE
FACILITY NUMBER: 197495032
VISIT DATE: 03/10/2022
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· Applicant 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.
· 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. · 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.

· Reporting requirements: Applicant must report any unusual incident or injuries to the Child Care Regional office by telephone within 24 hours and in writing within 7 days. Applicant was provided with LIC 624 as a reference.

· Fire and safety drills must be performed every six months and documented for review by the Department.

· 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.

· LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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