198000721-11-29-2023-54-CC-WBIS-CY2RFC-20231129115855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198000721
Report Date: 11/29/2023
Date Signed: 11/29/2023 11:59:13 AM

Document Has Been Signed on 11/29/2023 11:59 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	REBELLON, EDILMA FAMILY DAY CARE		FACILITY NUMBER:	198000721
ADMINISTRATOR:	REBELLON, EDILMA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 305-3606
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	14	CENSUS: 5	DATE:	11/29/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Edilma Rebellon		TIME COMPLETED:	12:10 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 (LPAs) Warren Birks and Angelica Wallin conducted an unannounced Required 3 Year inspection. LPA met with Licensee's Edilma Rebellon who guided LPA on a tour of the facility. Upon arrival LPA observed Licensee caring for five children (Two infants and three preschool). This is a two story home which consist of three bedrooms and three bathrooms and a back studio. The back studio has a cleared adult resident. The home also consist of the, living room, kitchen, dining area, garage and backyard. The Licensee uses a large den on the first floor, one bathroom and in an enclosed backyard play area for child care. LPA observed the play area to be clean and free of hazards at this time. LPA also the play area to have gates when needed to make areas inaccessible. LPA advised Licensee to make sure all tools and hazardous items in the backyard are inaccessible. LPA observed plenty of safe and age appropriate toys, books, educational items, arts and crafts materials. Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. There is a working telephone maintained in the home. Licensee has a small pet dog that is always inaccessible during daycare hours. LPA advised Licensee to provide extra care and supervision if animals are present with children as animals may be unpredictable. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible. LPA informed Licensee that poisons must be locked with a key or combination lock. Fire arms and pool regulations were discussed. Per Licensee there are no bodies of water and LPA did not observe any on the premises. The License, Parents Rights Poster, and Earthquake Preparedness was posted. The valve on the required 2A 10BC fire extinguisher indicates fully charged and is due for service in July 2024. Smoke and carbon monoxide detectors hallway and upstairs were tested and are in operable condition.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren Birks	TELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: REBELLON, EDILMA FAMILY DAY CARE	FACILITY NUMBER: 198000721
	VISIT DATE: 11/29/2023

NARRATIVE

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LPA observed the Licensee has the current Mandated Reporter training which expires in October 2025. LPA observed the Licensee and staff also have documentation indicating immunization regarding measles, pertussis and tuberculosis on file.

At approximately 11:00am LPA reviewed five children's files which include the documentation such as: Parent's Rights, Personal, Affidavit for Liability insurance, Identification and Emergency, Consent for Emergency Treatment, Additional Children in Care and Immunization records and Infant Safe Sleep documents. Licensee also documents 15 minute checks.

The following was discussed: Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty. LPA advised to ensure all adults that come into the home are fingerprint cleared and associated.

No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, and any other item that falls into that category are not permitted in the facility. Effective January 1, 2010, licensees of family child care homes are required to ensure that at least one staff member with current training in pediatric first aid and pediatric CPR is on site at all times when children are present. Licensee's CPR expires in July 2025.

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

LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and document the child's condition. The LIC 9227 Individual Infant Sleeping The plan shall be completed for each infant up to 12 months of age. LPA discussed the form and explained that the LIC 9227 form that is available on CCLD website.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren Birks	TELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: REBELLON, EDILMA FAMILY DAY CARE	FACILITY NUMBER: 198000721
	VISIT DATE: 11/29/2023

NARRATIVE

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The Licensee was advised on the inaccessibility of hazards, Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed. LPA informed Licensee regarding PIN 20-24-CCP. LPA discussed LIC 311D - Forms/Records to Keep in Your Family Child Care Home. Mandatory Forms for the children’s files and staff files, requirements for fire drills, earthquake drills and documentation were discussed. Role and responsibilities of being a Mandated Reporter were reviewed. The Licensee was advised how to access forms and Regulations online at www.ccld.ca.gov. Licensee was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care.

LPA consulted and explained Child Abuse Reporting, Updated Parent’s Rights Poster with Complaint Hotline information, Never Shake a Baby, Sudden Infant Death Syndrome (SIDS), and Safe Sleeping practices which always Baby is sleeping on his/her back. Capacity Handout (Small & Large) was provided during this inspection. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (use LIC624B for written report). Mandated reporter training must be completed every 2 years. www.mandatedreporterca.com. Licensee and staff have the required Mandated Reporter training.

LPA informed Licensee information regarding with Safe Sleep PIN 20-24-CCP. LPA also discussed Entrance Checklist form, Capacity and Ratio, and Items not Permitted. LPA explained these regulations and advised Licensee to ensure that she provides care and supervision adhering to the information provided.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. This report along with a copy of the appeal rights was provided. Exit interview was conducted with Licensee Edilma Rebellion.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren Birks	TELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/29/2023 11:59 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: REBELLON, EDILMA FAMILY DAY CARE	FACILITY NUMBER: 198000721
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)

Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above : Child 1,2 missing immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Licensee indicated she will provide immunization records for child #1 and #2.

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: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren Birks	TELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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