197700363-10-15-2019-12-CC-DMAX-BGYQ3M-20191015114858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197700363
Report Date: 10/15/2019
Date Signed: 10/15/2019 11:49:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550

FACILITY NAME:	VILCAPOMA FAMILY CHILD CARE		FACILITY NUMBER:	197700363
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	10/15/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Charity Vilcapoma		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maddox met with Charity Vilcapoma today for the purpose of conducting an announced prelicensing inspection. Present during this inspection was applicant only. The following adults reside in the home: applicant, spouse, Paulo Vilcapoma, father in law, Victor Vilcapoma, and mother in law, Elvira Vilcapoma and two minor daughters. Applicants hours of operation will be Mon-Fri from 6:30am to 6:00 pm. This is a two story single family home with 2.5 bathrooms and 4 bedrooms. The first floor consists of living room, dinning room, kitchen, 1/2 bathroom, and attached garage. The second floor consists of four bedrooms and two bathrooms. The off limits areas are the entire second floor and the attached garage. The garage entrance has a child proof knob in place. Home has central AC and heating. Both applicant's have current Pediatric CPR/First Aid expire on 09/2020. Preventative Health and Safety that includes one hour of child nutrition was completed on 09/05/2018 by both applicants. The required Mandated Reporter training was completed on 01/10/19 by Charity Vilcapoma and 03/10/19 by Elvira Vilcapoma. Child care orientation was completed on 08/16/18 by Charity Vilcapoma and 03/15/19 by Elvira Vilcapoma. Both applicants had the required immunization's.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Donna Maddox	TELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019

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, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550

FACILITY NAME: VILCAPOMA FAMILY CHILD CARE	FACILITY NUMBER: 197700363
	VISIT DATE: 10/15/2019

NARRATIVE

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The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation. Medications are stored in the off limits area locacated on second floor in a cabinet located in the master bedroom. Applicant has a fully stocked First Aid kit; Sharp knives are stored in the kitchen cabinet out of reach of children. Cleaning solutions are stored out of reach of children above the laundry machines in the laundry room. Per applicant, there are no weapons or firearms in the home. The stairs leading to the second floor were properly gated to prevent access. There is a community in ground swimming pool located directly across the street from applicants home, the pool is surrounded by 7ft wrought iron fencing and the gate opens away from pool area, key fob required to enter the pool area.

The primary care of children will be conducted in the living room, family room, backyard, and 1/2 bath. The living room has age appropriate toys, play equipment and materials. Children will use the 1/2 bathroom located downstairs. The home has an outside area that's completely fenced and can be accessed through the sliding glass door in the family room. Applicant will provide breakfast, lunch, and snacks depending on the children's schedule.

Applicants was informed that all adults living in or having access to the home, or are employees are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Central Index prior to having contact or working with children. 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 #1 week. The applicant was advised to utilize the Request for Livescan Service LIC9163 to have adults fingerprinted and associated to the home.

The applicant was advised of the requirement to report Unusual Incidents. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified specified above. The applicant was informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Donna Maddox	TELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019

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, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550

FACILITY NAME: VILCAPOMA FAMILY CHILD CARE	FACILITY NUMBER: 197700363
	VISIT DATE: 10/15/2019

NARRATIVE

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The following was discussed with the applicants:
Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter were reviewed; The applicants were reminded that 100% supervision is required at all times to children in care; Applicants were made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind during the operation of the day care; Upcoming safe sleep regulation for infants - printed out

The applicant was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

Beginning on January 1, 2018, Assembly Bill 1207 (2015) 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. Applicants must meet requirements as a precondition to licensure. New employees shall have 90 days from date of employment to complete training as required. The training may be conducted at the following website www.mandatedreporterca.com.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Donna Maddox	TELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019

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, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550

FACILITY NAME: VILCAPOMA FAMILY CHILD CARE	FACILITY NUMBER: 197700363
	VISIT DATE: 10/15/2019

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 - Applicant will provide IMS.

The applicant was advised it is her responsibility to visit the department's website to access licensing forms, Quarterly Updates and Provider Information Notices (PINs): www.ccld.ca.gov

Applicant is aware of the required documents that must be posted after licensuee. Notification of Parent's Rights Poster (PUB394), License, Emergency Disaster Plan (LIC610A), and Earthquake Preparedness Checklist (LIC9148).

Home was found to be in compliance with Title 22 Regulations, Exit interview conducted, copy of report printed and left with applicant.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Donna Maddox	TELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019

LIC809 (FAS) - (06/04)

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