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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198003193
Report Date: 07/29/2019
Date Signed: 07/29/2019 10:35:49 AM

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:MARTIN FAMILY CHILD CAREFACILITY NUMBER:
198003193
ADMINISTRATOR:MARTIN, LORENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 917-0798
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY:14CENSUS: 3DATE:
07/29/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Lorena MartinTIME COMPLETED:
10:40 AM
NARRATIVE
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ANNUAL RANDOM VISIT CONDUCTED IN ENGLISH
An Annual Random Inspection was conducted by Cynthia Reyes & Jonah Myson LPAs . Met with licensee, who guided the analyst on a tour of the facility on this date. This is a single story home. Residing in facility are 3 adults and 0 child. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Days & Hours M-F 7 AM-6 PM.

Areas used by children were inspected as follows: Kitchen, living room, dining room, 1 bedroom, master bedroom 2 bath rooms (1 in the back yard), and Garage (day care room) front and back yard.

There is a weapon, and no *swimming pool on the premises. The backyard is adequately fenced. There are age appropriate toys and equipment on the premises. The smoke detectors, carbon monoxide and fire extinguisher (2A 10BC) are in operable condition.

Areas off limits include: 1 Bedroom (sons room), and the master bathroom.
**Rooms that are off-limits need to be made inaccessible during operating hours** .

**Child Care Roster (None), Disaster Plan, Emergency Disaster Drill and Children's Records were reviewed.
**Children records and required licensing forms were discussed as well as mandated child abuse reporting and criminal records clearance (finger prints and child abuse clearance) requirement.

***Web site address to order forms: http://www.dss.cahwnet.gov/cdssweb/On-lineFor_293.htm#l

***INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Cynthia ReyesTELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2019
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MARTIN FAMILY CHILD CARE
FACILITY NUMBER: 198003193
VISIT DATE: 07/29/2019
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

Employees or volunteers at family day care home; immunization requirements; records; exemptions Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.



Availability of information regarding detecting and reporting child abuse and neglect; training for mandated reporter on or before March 30, every two years following 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training the date on which he or she completed the initial mandated reporter training and submit proof of completion.

AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com/
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Cynthia ReyesTELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MARTIN FAMILY CHILD CARE
FACILITY NUMBER: 198003193
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2019
Section Cited
CCR
102417(g)(8)
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Operation of a Family Child Care Home.
All homes shall have a current roster of the children.
The requirement is not met as evidenced by
Licensee did not have a completed or updated roster. This is a potential risk to the health and safety of children in care.
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Licensee states will complete a roster and send a copy to the department by the POC date.
Type B
08/05/2019
Section Cited
CCR
102418(g)
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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. This requirement is not being met as evidenced by: file review of several children not containing proof of immunization's. This is a potential risk to the health and safety of children in care.
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Licensee states will do a file review of all children enrolled file and will ensure all children have the required Immunization's and send proof by the Plan of Correction due Date (POC)
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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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Cynthia ReyesTELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MARTIN FAMILY CHILD CARE
FACILITY NUMBER: 198003193
VISIT DATE: 07/29/2019
NARRATIVE
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The following was discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to licensure. Individuals within one month of their 18th birthday must be fingerprinted immediately. The existing, immediate $100 per individual Civil Penalty has been increased to an immediate $100 per day Civil Penalty, for a maximum of five days for the first violation and a maximum of 30 days for subsequent violations. If an individual has a clearance with the Department a criminal record clearance may be transferred. LIC 9182 Criminal Background Clearance Transfer Request may be used. NO smoking, infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category, earthquake – fire, disaster drills and safety, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal records, child abuse clearance and criminal records transfer requirements, SIDS, Never Shake A Baby were discussed.

Applicant has been advised of the following:.
· Pools should be inaccessible by a pool cover or a 5-foot fence around the perimeter of the pool. If the fence is made out of chain link, the opening should not allow a golf ball to pass through. Fences made out of mesh will need to be approved by the department. Mesh fence will remain in place whenever licensed care is provided, and as long as the mesh fence makes the swimming pool inaccessible to children as determined by licensing staff- Licensee’s initials ( ).
· Pool cover label should read F1346-91 American Society for Testing Material and it should be able to withstand the weight of an adult without water above cover when standing.
· Dog(s) and or pets should be isolated from children in care.
· It is recommended that a First Aid kit be available on premises.
***100% Outdoor supervision is required at all times. If outdoor area not adequately fenced provider must be with children at all times when outdoors. Licensee's Initials( ).

The following deficiency's are cited in accordance with Title 22 of California Code of Regulations and discussed with licensee: See 809 D for citation. Consultation conducted on this date

An exit interview conducted with licensee, appeal rights, progressive civil penalties were explained including a copy of this report was given to the licensee and LIC 9213—Notice of Site Visit was posted during this visit. Notice of Site Visit must be posted for 30 days. Failure to post required visit reports for 30 consecutive days will result in immediate civil penalty assessment of $100.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Cynthia ReyesTELEPHONE: (323) 981-3369
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4