198012661-5-20-2019-33-CC-CGOZ-BCCMWP-20190520095841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198012661
Report Date: 04/29/2019
Date Signed: 05/20/2019 10:19:36 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:	SMITH FAMILY CHILD CARE		FACILITY NUMBER:	198012661
ADMINISTRATOR:	SMITH, TARA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 351-5240
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	10	CENSUS: 9	DATE:	04/29/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Tara Smith, Licensee		TIME COMPLETED:	12:00 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 (LPA) Carlos Gonzalez, conducted an Annual/Random inspection on this date, for an increase in capacity. LPA met with Tara Smith, Licensee, who guided Analyst on a tour of the facility. Also present were Licensee's parents, William and Barbara Jackson, and Assistant Sandra Wright. LPA observed nine (9) children in care at the time of inspection. A facility roster was provided at the time of inspection and is current. This is a single story home consisting of 3 bedrooms, 2 bathrooms, living room, den, kitchen, and dining room area. There is also a detached garage, primarily used as a children's activity area. Children use the living room and den for napping purposes. There is also, an outdoor (rear) back yard used for outdoor play. There is a fireplace in the living room and LPA observed a barrier (metal/glass), to prevent children from gaining access. LPA observed a 2-A:10-B:C fire extinguisher, which was last serviced on 05/31/18. The smoke and carbon monoxide detectors were tested and are operable. There are first supplies available. Licensee's First Aid/CPR card has an issuance date of 09/2017 (Expires 09/2019). Licensee was observed to be operating within the licensed capacity limitation's during this inspection. There is one (1) child enrolled that requires Incidental Medical Services (IMS) at this time. LPA observed a Nebulizer device kept in a backpack in a locked cabinet, in the children's activity area. Per Licensee, training was provided via the child's parent, and via the case worker of Pacific Clinics. Per Licensee, there are no firearms, weapons, or pets on the premises. LPA did not observe any bodies of water on the premises. LPA determined that Licensee last conducted an earthquake drill on 04/01/2019, per the log provided. The facility license, Emergency Disaster Plan, and Parents Rights Notice, were observed to be posted. Report continues on next page 1 of 2

SUPERVISOR'S NAME: Katherine Harewood	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Carlos Gonzalez	TELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2019

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: SMITH FAMILY CHILD CARE	FACILITY NUMBER: 198012661
	VISIT DATE: 04/29/2019

NARRATIVE

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There were zero (0) deficiencies observed during this inspection. Licensee is in compliance with California Code of Regulations, Title 22 requirements.

Notice of Site Visit (LIC 9213), must remain posted for 30 days, during the hours of operation. Failure to maintain posting as required, will result in a $100 civil penalty.

Exit interview conducted with Tara Smith, Licensee.

Report ends page 2 of 2

SUPERVISOR'S NAME: Katherine Harewood	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Carlos Gonzalez	TELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2019

LIC809 (FAS) - (06/04)

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