198011279-1-3-2024-33-CC-SLII-CZ5QGQ-20240103110955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198011279
Report Date: 01/03/2024
Date Signed: 01/03/2024 11:10:09 AM

Document Has Been Signed on 01/03/2024 11:10 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	CHAVEZ FAMILY CHILD CARE		FACILITY NUMBER:	198011279
ADMINISTRATOR:	CHAVEZ, URSULA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(909) 247-0140
CITY:	POMONA	STATE: CA	ZIP CODE:	91766
CAPACITY:	14	CENSUS: 0	DATE:	01/03/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Licensee Ursula Chavez		TIME COMPLETED:	11:20 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

At 9:15am, Licensing Program Analysts (LPA)s Stephanie Li and Nolan Tcheng conducted an unannounced required 3 year inspection to the above facility. A risk assessment was conducted upon entry. LPA's met with Licensee, Ursula Chavez who guided analysts on a tour of the facility. Per Licensee, there are currently 7 children enrolled. A current children’s roster was available for review. There were 0 children present upon arrival. Facility capacity is in compliance for a Large Family Child Care Home. Hours of operation are Monday-Friday, 7:00am-6:00pm.

This is a two story home which consists of 3 bedrooms, 3 bathrooms, living room, day care room, kitchen, wash room, garage, front yard and backyard (fenced). Currently residing in the home are 2 adults and no minor children.

All adults present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in the licensed child care home.

Areas accessible to children were inspected as follows: kitchen, living room, dining room, daycare room, 1 bathroom, front yard and back yard. No children were present at time of inspection. Fire place in living room was observed to be sealed. Stairs leading to second floor were observed to have a gate to restrict access.

page 1 of 4

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Stephanie Li	TELEPHONE: (626) 366-3362
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHAVEZ FAMILY CHILD CARE	FACILITY NUMBER: 198011279
	VISIT DATE: 01/03/2024

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
26
27
28
29
30
31
32

Per licensee, areas off limits to children and parents, 3 bedrooms, 2 bathrooms, wash room and garage. The LPA's toured all areas used by children during this visit. Licensee states that there are no weapons or fire arms on the property. No bodies of water were observed.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is telephone service via a cellphone that stays at the facility during operation hours.

The following was observed and reviewed during this inspection:

LPA observed the following required posted documentation in the main entry way of the facility: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA reviewed facility records for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Last drill documented was conducted on 12/23/2023.

The home is observed to be clean and orderly, with central air and heating. There are toys available for children. Sleeping equipment not observed as licensee services school age children. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 10/5/2023, as indicated on service tag. Smoke and carbon monoxide detectors were tested and are operable. Detergents, cleaning compounds, and medications were observed to be inaccessible to children. Per Licensee, there are no poisons in the home. and understands that all poisons must be locked, to be made inaccessible to children. Licensing staff reminded licensee smoking is not allowed in a family child care home. The restroom that children use was observed to be safe and sanitary.

page 2 of 4

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Stephanie Li	TELEPHONE: (626) 366-3362
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHAVEZ FAMILY CHILD CARE	FACILITY NUMBER: 198011279
	VISIT DATE: 01/03/2024

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
26
27
28
29
30
31
32

LPA's discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleepas an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Currently, children are using the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA's observed that the outdoor yard has toys and other materials for children to play with. LPA's did not observe any objects that can pose a danger to children in the outdoor yard.

The licensee is observed to be operating within the license capacity limitations.
Children’s records were reviewed, including emergency information and were observed to be complete. The licensee has completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 02/05/2024. Licensee has current Mandated Reporter AB 1207 compliant Child Care Training Certificate on file expires on 10/7/2024. LPA's observed that the Licensee does have proof of immunizations.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

page 3 of 4

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Stephanie Li	TELEPHONE: (626) 366-3362
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHAVEZ FAMILY CHILD CARE	FACILITY NUMBER: 198011279
	VISIT DATE: 01/03/2024

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
26
27
28
29
30
31
32

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

LPA's advised the licensee to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During the exit interview, the LICENSEE Ursula Chavez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Ursula Chavez.

page 4 of 4

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Stephanie Li	TELEPHONE: (626) 366-3362
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4