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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198003989
Report Date: 07/08/2019
Date Signed: 07/08/2019 05:19:00 PM

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:JOHNSON FAMILY CHILD CAREFACILITY NUMBER:
198003989
ADMINISTRATOR:JOHNSON, PAMELLA MAXINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 612-0904
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:14CENSUS: 4DATE:
07/08/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Pamela JohnsonTIME COMPLETED:
05:25 PM
NARRATIVE
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An Annual Random inspection was conducted by Licensing Program Analyst, Jennifer Hua PA. Met with licensee, who guided the analyst on a tour of the facility on this date. This is a two story home. Residing in facility are 3 adults and 2 minors. 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. Licensee's spouse also present during this visit.

Areas used by children were inspected as follows: Kitchen, living room, dining room w/family room, play room, art/eating room, bathroom and fenced back yard

Per licensee, there are NO weapons, firearms, swimming pool or spa 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.

Licensee is current in Pediatric First Aid/CPR, certificate expires on 2/2020.

Areas off limits include: Garage, Entire Upstairs (7 rooms & 2 bath rooms) & front Yard.
**Rooms that are off-limits need to be made inaccessible during operating hours** .

Child Care Roster, Disaster Plan, Emergency Disaster Drill and Children's Records were reviewed. Affidavit regarding Liability Insurance form in files. Drills conducted on 6/2019.
SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2019
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 198003989
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2019
Section Cited
CCR
102417(g)(1)
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OPERATION OF A FAMILY CHILD CARE HOME. Fire extinguishers shall meet State Fire Marshal standards. The requirement is not met as evidenced by: Fire extinguisher is not serviced annually. This poses a potential risk to the health and safety of children in care.
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Per licensee, will service it tomorrow and submit copy of invoice and service tag to LPA by the POC due date of 7/10/19.
Type B
07/10/2019
Section Cited
HSC
102421
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Child's Records. The requirement is not met as evidenced by: 1 child's record lack form LIC 9166 - Nebulizer/inhaled medication consent form. This poses a potenital risk to the health and safety of children in care.
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Per licensee, will have parent complete form at pick up and obtain all required documents as required and submit copy to LPA by the POC due date.
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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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 198003989
VISIT DATE: 07/08/2019
NARRATIVE
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Children records and required licensing forms were reviewed as well as mandated child abuse reporting and criminal records clearance (finger prints and child abuse clearance) requirement. Licensee completed the Mandated Reporter Training on 5/17/18.

Incidental Medical Services (IMS):
The facility provides. Incidental Medical Services (IMS). LPA reviewed storage of medication and equipment/supplies, and reviewed children's, personnel, and administrative records. 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.

Licensee will submit IMS plan by 7/12/19.

No smoking, No infant walkers, No Johnny jumpers, No exersaucers, bouncers and any other item that falls into that category are not permitted in the facility. Discussed disaster drills, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal records clearance, child abuse clearance, and criminal records transfer requirements, SIDS and Never Shake a Baby. A provider's Guide to Safe Sleep was provided and discussed.

WEB SITE ADDRESS is (www.ccld.ca.gov). Issued handbook on Child Abuse Reporting, Never Shake a Baby, and SIDS.

The following is being cited in accordance to Title 22 of the California Code of Regulations and Health & Safety Codes. Please refer to 809D for documentation of deficiencies. See 809D.

Notice of Site Visit Form was provided and explained. Form must be posted for 30 days in a prominent area or a civil penalty of $100.00 will be assessed.
Exit interview was conducted with Licensee, a copy of report given.
SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2019
LIC809 (FAS) - (06/04)
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