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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700110
Report Date: 11/09/2022
Date Signed: 11/09/2022 10:47:26 AM


Document Has Been Signed on 11/09/2022 10:47 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:DUOBERT-CHUMBE FAMILY CHILD CAREFACILITY NUMBER:
197700110
ADMINISTRATOR:DUOBERT-CHUMBEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 478-8581
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:14CENSUS: 0DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Mercedes DuobertTIME COMPLETED:
11:00 AM
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On 11/9/2022, Licensing Program Analyst (LPAs) Carol Heath and Kuliema Calloway conducted an unannounced Required 1-Year inspection at the Duobert-Chumbe Family Child Care. Upon arrival, the LPA met with the licensee, Mercedes Duobert-Chumbe who guided the LPA on a tour of the facility. Family members residing in the home include 2 adults (The license and her husband) and no children. All adults living in the home have been background cleared. Per the licensee, the hours of operation are Monday through Friday 23 hours. During this inspection, 0 childcare children. Incidental Medical Services (IMS) were discussed.

The Home is set up as follows:
This is a two-story home with 4 bedrooms, 3 bathrooms, a kitchen, a family room, a living room/dining room, a den, a laundry room, a garage, and a backyard. Parents will enter childcare through the front door. The home was inspected for safety, comfort, cleanliness, telephone service, central air, and heat and ventilation. The home has central heating and air conditioning. All windows have screens and are free of cracks, bugs, and debris.
Ø Main Area: Child care is to be provided in the family room and downstairs bedroom. Children will use the bathroom down the hall on the left.
· Bedroom #1 / Family room: LPA observed age-appropriate toys and furniture for the children. LPA observed: A small table was observed with a total of eight chairs. Several plastic storage bins were observed in which games and toys are stored for the children. A small play kitchen was located by the door with which children can play. There are games and books on the premises of this facility. There are mats on the floor that have educational/learning activities on them. The mats were observed to be in good condition.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 11/09/2022 10:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA observed many adult tools in the backyard and dog poop, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2022
Plan of Correction
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The license will clean up her backyard and send pictures to LPAS.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above . LPA did not observed her assistant's IZ record (MMR and Dtap) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2022
Plan of Correction
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The license will email or text to LPA.

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: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 11/09/2022
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· Children's Bathroom (#1): Children use the bathroom down the hallway next to the kitchen. The Bathroom was toured and inspected sink/toilet is in operable condition. Toilet and faucets are clean, safe, and operable. All poison and medications are made inaccessible to children with child safety latches on the sink cabinet and drawers. The bathroom was observed to be free and clear of hazardous items. The bathroom was clean, sanitized, and in good repair.
· Kitchen/Dining Room: The kitchen was inspected to ensure dangerous items were inaccessible to children (Safety latches). Kitchen cabinets and drawers were observed to have child locks. Knives are kept on a high shelf in the kitchen pantry (child safety knob observed). Cleaning compounds and detergents are also kept on a high shelf in the pantry. Medications are stored in a high kitchen cabinet, and a padlock is observed for inaccessibility.
· Backyard: The backyard was inspected; The backyard is gated all around. Children play in the backyard. There is a large, empty pond structure in the backyard that is gated by a chain link fence. LPA observed the structure has water due to the rain yesterday. . Regulations on bodies of water and proper gating were discussed with The license in the event that the structure was ever filled with water. The license stated that the structure will remain empty (declaration obtained). LPA observed age-appropriate toys and play equipment. There is a sandbox in the corner of the backyard (observed covered). LPAs many adult equipments in the backyard assisible to the children. Also LPA observed dog poops in the backyard.
Ø Off-limit: Off-limit areas include the entire gated 2nd floor and the garage. Laundry room is in offlimit upstairs area.
Ø Others:
· AC/Heating Unit was observed. AC/Heating Unit is located on the right side of the home is inaccessible to children via barrels blocking access to the unit.
· Bodies of water: Per licensee, There is a large, empty pond structure in the backyard that is gated by a chain link fence. LPA observed the structure has water due to the rain yesterday. . Regulations on bodies of water and proper gating were discussed with The license in the event that the structure was ever filled with water. The license stated that the structure will remain empty (declaration obtained).
· Electrical outlets: All unused electrical outlets are plugged in and made inaccessible to children.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 11/09/2022
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· Fire extinguisher (2A10BC): LPA observed there is a required fire extinguisher (2A10BC) fully charged and located in the kitchen inaccessible to children. It meets standards established by the State Fire Marshall (reading in green and receipt of purchase observed).
· Fireplace: No Fireplace
· Hanging window blind cords: The cords are accessible to children.
· Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. The Licensee will not be providing IMS to the children at this time.
· Isolation area (Illness): Per licensee, if the child shows signs of illness, he/she will be separated from other children and stay in Family Room.
· Medications and cleaning solutions: Detergents/cleaning compounds are in upper kitchen cabinet. Medications are in the off-limits bedroom.
· Napping: Children will nap in the designated nap areas with adult supervision. LPA observed 7 mats in the closet.
· Overnight Care: Pre-licensee, does not provide overnight care. Not at this time.
· Pets: 1 small dog. It has current vaccinations.
· Phone service: There is a working landline or cell phone
· Smoke Detectors and Carbon Monoxide: The smoke detectors and carbon monoxide devices tested operable.
· Stairs (For two-story hours): There is a safety gate barricaded to make the stairs inaccessible to the children.
· The First Aid kit is located in the key-locked closet inaccessible to children. The First Aid Kit was observed complete with supplies and a first aid manual.
· Transportation: The licensee will not transport daycare children.
· Weapons or Firearms: Per Licensee, there are no Firearms at the facility at this time. LPA does not
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 11/09/2022
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observe any firearms.
Ø Documentation:
· Child files: LPA observed 6 children's files contained all required licensing documents.
· CPR/First Aid: LPA observed licensee has current Pediatric CPR and First Aid Training with an expiration date (09/2021) 1 hour of nutrition training, (8) hours of Preventive Health and Safety Training.
· Criminal Record: Pre Guardian, all adults who live in this facility obtain a criminal record clearance.
· Facility fees: Per Licensing Information System, facility annual fees were current.
· Fire Drill and Disaster Drill: Per the licensee, fire and disaster drills are conducted every 6 months; the last drill was documented and conducted on 08/19/2022.
· Immunization: The licensee and her assistant have the required immunizations (MMR and DTaP). The licensee and her assistant provided a written statement declining the influenza vaccination.
· Infant Sleeping Plan (LIC 9227) and Sleeping Log: LPA shared the information with the licensee. Per Licensee, there is NO infant (0-12 months) enrolled in the facility.
· The licensee has posted as required the Facility License, Emergency Disaster plan, Earthquake Preparedness, and Parent's Rights Poster
· Mandated Reporter Training: The licensee has completed and renewed the online mandated reporter training at www.mandatedreporterca.com on 2/17/2022
· Staff Personnel File: LPA observed 1 staff information. LPA observed LIC 508, 9052, IZ, TB test, LIC 9108, Mandated Reporter Training, and CPR/First Aid certificates. The assistant is missing MMR and Dtap shot Record.
· Staffing Ratio and Capacity: This is a large family childcare facility. LPA observed 0 children during the inspection.

Ø The following information was discussed with the licensee:
ü Mandatory Forms for the children’s files and provider’s files.
ü Requirements for fire drills, earthquake drills, and documentation for both.
ü The role and responsibilities of being a mandated reporter were discussed.
ü The licensee is reminded that 100% supervision is required for children at all times.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 11/09/2022
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ü Capacity requirements, Roster requirements, Posting requirements, and Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children’s files and provider’s files, and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. The licensee was reminded that supervision is always required for children in care.
ü State law prohibits baby walkers, bouncy seats/chairs, exersaucers, and any other items that fall into that category.
ü The licensee was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care. The licensee was advised that the inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified.
ü The licensee 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 and on the form LIC624B
ü The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also, call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).
ü Criminal Record Statement: Licensee [or facility representative] 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 the 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.
ü Safe Sleep: LPA discussed the safe sleep regulations with the licensee [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 the licensee [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.
ü Notice of Site Visit: A notice of site visit was given and must remain posted for 30 days.
ü Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 11/09/2022
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ü Type A citation: LPA (name of analyst) informed licensee [or facility representative] (include name) that this report dated (insert visit date) document(s) (number of Type A citation) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA (name of analyst) informed the licensee [or facility representative] to provide a copy of this licensing report dated (insert visit date) that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
ü The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers, and any other items that fall into that category.
ü --Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
n Our Quarterly updates come out every 3 months they are also now in Spanish please log in to the CCLD website or you can email our advocates to have the quarterly updates sent directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

ü The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 AM - 5:00 PM.

ü A copy of the Safe Sleep Proposed Regulations was provided to Licensee.

ü LPA provided consultation during the inspection.

Deficiencies cited: (See LIC 809D). The following Type B deficiencies are being cited in accordance with Title 22 of the California Code of Regulations and/or Health & Safety codes.



Exit interview conducted and the report was reviewed with the licensee Mercedes Duobert-Chumbe.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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