198008304-4-5-2022-33-CC-NTCG-CD7NS9-20220405104247

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198008304
Report Date: 04/05/2022
Date Signed: 04/05/2022 10:42:58 AM

Document Has Been Signed on 04/05/2022 10:42 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	MEDINA FAMILY CHILD CARE		FACILITY NUMBER:	198008304
ADMINISTRATOR:	MEDINA, SUSANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 793-8597
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 12	DATE:	04/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Susana Medina - Licensee		TIME COMPLETED:	10:56 AM

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) Nolan Tcheng conducted an unannounced annual random inspection to the above facility. At 8:50am, LPA met with licensee, Susana Medina. Also present during this inspection was the assistant, Licensee’s daughter. The licensee states that she currently has 14 children enrolled. A current children’s roster is available and is current. Licensee’s hours of operation are 7am-10:30pm, Monday-Sunday. This is a one-story home which consists of 2 bedrooms, 2 bathrooms, kitchen, living room, infant room, front yard (fenced), side yard (fenced) and backyard (fenced). The children use living room, front bathroom, infant room, Bedroom #1 and side yard and front yard. Per licensee, areas off limits to children and parents include: back yard, Bedroom #2, back bathroom and kitchen. The licensee provides food for children in care. The licensee states that 5 adults and 1 child currently live in the home. Persons living in home are identified on the attached LIC811. Licensee states that she currently has two assistants. Staff are identified on the attached LIC859. All individuals present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in a licensed home. Per licensee, there are no weapons, firearms or bodies of water on the premises. PHYSICAL PLANT At 9:00am, LPA was lead on a tour of the facility by the licensee. The entrance of the facility leads straight into the living room. There are cubbies on the left for children in care. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are observed to be posted. There were children present during the time of inspection having breakfast. There were age appropriate toys and equipment present in the living room for children in care. LPA observed Detergents, cleaning compounds, medications, and other items which could pose a danger are inaccessible to children throughout the home by being place up high out of reach. Per licensee, the front living room/hall area will be used as an area for an ill child until an authorized representative comes to pick up child. REPORT CONTINUES PAGE 1 of 3

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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: MEDINA FAMILY CHILD CARE	FACILITY NUMBER: 198008304
	VISIT DATE: 04/05/2022

NARRATIVE

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There are first aid supplies available by the front door. At 9:07am, a fire extinguisher was observed. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 08/11/2021, as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. Smoke and carbon monoxide detectors were tested and are operable. The licensee states that there is a land line on the premises. LPA observed the bathroom which has a changing table present for infants in care. The bathroom was observed to be safe and in good condition, free of any hazards. LPA observed napping equipment in the form of cots. There were two play yards in the infant room. Infant room was observed to have age appropriate toys and equipment. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock.

At 9:15am, LPA observed the outdoor area. The outdoor play area was observed to be fenced. At this time, children are using the side yard that has space for children in care, there is a covered section that has age appropriate toys, books, and equipment for children in care. The facility also uses a front yard area that is grass and has equipment for children in care. The licensee is observed to be operating within the license capacity limitations.

FACILITY RECORDS:

The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 09/2023. Licensee and personnel have complete mandated reporter training that expires on 12/03/2023. The licensee does have proof of immunization against influenza, tuberculosis, pertussis, and measles. Children’s records were reviewed, including but not limited to, a copy of the emergency information card that contains all the information specified by regulation.

The following was discussed:

-Individuals who are 18 years of age or older living in the home must be finger print cleared prior to being in the presence of the children in care. Individuals within one month of their 18th birthday must be fingerprinted immediately.
-There are no pets on the premises.
-Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that falls into these categories are not permitted in a family child care facility.
-Smoking is prohibited in a license family child care home.
REPORT CONTINUES PAGE 2 of 3

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

Page: 2 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: MEDINA FAMILY CHILD CARE	FACILITY NUMBER: 198008304
	VISIT DATE: 04/05/2022

NARRATIVE

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Infant Care: Licensee states that they are currently caring for infants. LPA advised the licensee to sleep infants where they can be directly supervised at all times and advised the licensee against sleeping infants in a separate room. Licensee states that infants sleep in the infant room. LPA provided the licensee with a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics and Helping you to reduce the risk of SIDS. 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. PIN 20-24-CCP was provided and explained during the inspection.

Incidental Medical Services (IMS):

The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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 observed COVID health and safety practices being conducted at facility. Signs were posted throughout the facility.

LPA advised the licensee how to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov. AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com/

At this time, the licensee is in compliance with California Code of Regulations Title 22. No deficiencies cited.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit made by a licensing representative.

Exit interview was conducted with Brenda Medina, Licensee's Assistant, at 10:40am. Copy of report was provided.

END OF REPORT PAGE 3 of 3

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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