197700253-12-28-2021-12-CC-LKIG-CA63J7-20211228171702

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197700253
Report Date: 12/28/2021
Date Signed: 12/28/2021 05:17:22 PM

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:	SMITH FAMILY CHILD CARE		FACILITY NUMBER:	197700253
ADMINISTRATOR:	SMITH, CHAUNCY&DENISHAY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 480-4280
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	14	CENSUS: 0	DATE:	12/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Chauncy Smith		TIME COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) King-Lewis conducted a required 1 year Inspection with licensee Chauncy Smith who guided analyst on a tour of the license day-care. The day care take place in the following area of the home: downstairs bedroom, down stairs bathroom, living room, family room, kitchen, dining area and rear yard. Licensee stated the facility provides 24 hours care 7 days a week. Licensee understand child care shall be less than 24 hours. Currently living in the home are the licensees and licensee's minor son.

Physical Plant:

LPA observed a trampoline in rear yard LPA informed licensees of the injuries reported due to the use of trampolines and informed licensees to made sure the trampoline is use as directed and age appropriate. LPA informed licensee the trampoline is not in good repair and should not be used by day care children until repairs are made. LPA observed an above ground pool located in rear side yard on the premises with a wrought iron gate with a door that swing open away from the pool that self close and self latches. Licensee stated a firearm is storage in a lock safe in the off limit area of the home and the almo is store separately. Storage areas for poisons, medication shall be inaccessible to children, stored in the off limit upstairs laundry room and

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

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 8

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: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197700253
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(d)

Operation of A Family Child Care Home

(d) The home shall provide safe toys, play equipment and materials. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above due to the trampoline in rear yard used by day care child in not in safe working condition, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/04/2022
	Plan of Correction
1 2 3 4	Licensee stated the trampoline will be repaired or removed from the premises.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC809 (FAS) - (06/04)

Page: 2 of 8

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: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197700253
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)1

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and record review the licensee did not comply with the section cited above due to the facility has not counted a fire or emergency drill in the last 6 months.
	POC Due Date: 02/04/2022
	Plan of Correction
1 2 3 4	Licensee stated a fire and emergency drill will be conduct prior to the plan of correction date and forward to LPA email.

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: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC809 (FAS) - (06/04)

Page: 3 of 8

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: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197700253
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and record review the licensee did not comply with the section cited above due to LPA was not able to review a current CPR/First Aid card or certificate for Licensee Denishay Smith which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/04/2022
	Plan of Correction
1 2 3 4	Licensee stated a current copy of licensee's CPR/First Aid card/certificate will be forward to LPA email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC809 (FAS) - (06/04)

Page: 4 of 8

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: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197700253
	VISIT DATE: 12/28/2021

NARRATIVE

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licensee's bedroom. Detergents, cleaning compounds and other items which could pose a danger to children are inaccessible to children stored in upstairs laundry room. LPA observed screen fireplace inaccessible to children. Fire extinguishers, smoke detectors, and carbon monoxide appear to be operable during the inspection. LPA observed the home to be clean and orderly, central air and heating available. LPA observed Barricaded stairs. Licensee stated a land line telephone is available for the day care as well as a cell phone. LPA did observe a crib for infant care with a firm mattress. Licensee stated he had read the safe sleep regulation. Licensee stated he is not currently caring for any infants. Licensee aware when infants are present the crib shall be free from loose articles and objects.

Licensee aware no infant shall be swaddle and car seat shall not be used for sleeping. Licensee is aware to supervise infants while they are sleeping by physically checking every 15 minutes and documenting the child status. Licensee is aware all infants shall have an individual infant Sleeping Plan (LIC 9227). Licensee should refer to regulation 102425(J) for documentation requirement. LPA reviewed requirement with licensee during this inspection visit. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC809 (FAS) - (06/04)

Page: 5 of 8

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: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197700253
	VISIT DATE: 12/28/2021

NARRATIVE

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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 publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Care and Supervision

License care providers shall be present in the home and shall ensure children in care are supervised at all times. License care providers that provides transportation shall make sure the transportation vehicle is proper insured to transport day care children. Licensee is aware the capacity stated on the facility license shall be the maximum number of children being cared for at one time.

Facility Records Review

LPA did not observe a current fire and disaster drill, LPA observe mandated reporter training certificate and facility roster. Licensee is aware that all employees or volunteer at the day-care shall be immunized against pertussis and measles and maybe immunized against influenza.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC809 (FAS) - (06/04)

Page: 6 of 8

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: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197700253
	VISIT DATE: 12/28/2021

NARRATIVE

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Facility Administration

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.

Licensee aware to immediately remove individual and prevent individual for returning to the home or having contact with children in care upon notice from the department to remove an individual and all individuals subject to a criminal record review shall obtain a criminal record clearance or exemption prior to working, residing or volunteering in the license home. Licensee is aware any authorized employee of the Department may enter and inspect any place providing personal care and services at any time with or without advance notice. Licensee is aware other personnel shall complete training on preventive health practices including CPR and first aid per regulation 102416 (c). Licensee Chauncy Smith CPR and first aid card expires 2-01-2023.

Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in writing within 7 day of incident on the form LIC624B per the regulation.

During this inspection facility was observed not to be in compliance with Title 22. Please see LIC 809D for deficiencies.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC809 (FAS) - (06/04)

Page: 7 of 8

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: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 197700253
	VISIT DATE: 12/28/2021

NARRATIVE

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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Exit interview conducted and report was reviewed with the licensee a copy of this report and a notice of site visit was given and must remain posted for 30 days

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC809 (FAS) - (06/04)

Page: 8 of 8