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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013326
Report Date: 07/02/2019
Date Signed: 07/02/2019 04:15:45 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:DAVIS FAMILY CHILD CAREFACILITY NUMBER:
198013326
ADMINISTRATOR:DAVIS, ELAINE & WENDELLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 805-0005
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:14CENSUS: 7DATE:
07/02/2019
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Licensee Elaine DavisTIME COMPLETED:
04:10 PM
NARRATIVE
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An unannounced, comprehensive Annual/Required inspection was conducted on this date by Licensing Program Analyst (LPA) B. Emiko Bell.

The inspection is due to Licensee being placed on required inspections for three years commencing 09/29/17 as a result of violations in the following areas: Criminal Record Clearance, Operation of a Family Child Care Home, Immunization, Personnel Requirements, Children's Records, Personnel Records, and Admission Procedures and Parental & Authorized Representative Rights.

Upon arrival, LPA was greeted and let into the residence by licensee, to whom the reason for the inspection was announced.

Census: Staff-child ratio was met. (See 812 for details.)

Licensee's days and hours of operation are 24/7, though Licensee stated that she does not currently have children at night or during the weekends. This is a two-story, single family residence with four bedrooms and four bathrooms. All areas identified on the facility sketches were inspected in the following order: (indoors): the kitchen, the converted garage, the dining room, the "sick room," a bathroom, an extra room
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019
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 7
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: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 198013326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2019
Section Cited
CCR
102417(9)(A)(1)
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OPERATION OF A FAMILY CHILD CARE HOME
Each family child care home shall conduct fire drills and disaster drills at least once every six months.The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home.
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Licensee stated that she will run a fire drill and log the date and time by the POC due date of 07/12/19. Verification will be provided to CCL via e-mail, fax, or mail.
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-This requirement is not met as evidenced by: Licensee has a fire drill log, but only the dates are noted, though the log itself states "Date and time". *This poses a potential risk to the health and safety of the children in care.*
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Type B
07/12/2019
Section Cited
CCR
102417(9)
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OPERATION OF A FAMILY CHILD CARE HOME
Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan.
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Licensee stated that she will obtain a blank LIC 610A and complete it by the POC due date of 07/12/19. Verification will be provided to CCL via e-mail, fax, or mail.
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-This requirement is not met as evidenced by: Licensee does not have an Emergency Disaster Plan. *This poses a potential risk to the health and safety of the children in care.*
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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: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 198013326
VISIT DATE: 07/02/2019
NARRATIVE
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As there are 20 children enrolled; five files were reviewed for the required forms. All files were checked for all forms as listed on LIC 311D and all are complete. The Licensee, her spouse and all of the assistant's files were also reviewed for completeness. (See LIC 811 for details.)

*During today's visit, the Confidential Names list was provided to the Licensee.*

The Notice of Site Visit was posted by Licensee in LPA's presence. The Notice of Site Visit shall be posted for thirty (30) consecutive days. Failure to maintain posting as required will result in the issuance of a citation and the assessment of a $100 civil penalty.

An exit interview has been conducted with and a copy of this report has been signed by and provided to Licensee Elaine Davis. Appeal Rights have been provided and explained to Licensee as well.
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 198013326
VISIT DATE: 07/02/2019
NARRATIVE
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Firearms: Licensee stated that there are currently no firearms or weapons on the premises.

Incidental Medical Services: This 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 Child Care Centers Section 102417. 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.

Backyard: The backyard is fenced on all three sides by a 6' tall brick wall; there is a grill in the backyard which has a cover on it.

Paperwork: Licensee has a Child Care Facility Roster. Licensee's Pediatric First Aid/CPR was issued by the American Heart Association and expires 09/20. Licensee completed the Mandated Reporter Training on 03/02/18. Licensee could not provided verification of MMR and TDAP immunizations and influenza declination.
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 198013326
VISIT DATE: 07/02/2019
NARRATIVE
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Parent Board: Licensee does not have a Parent Board. Licensee has her license in a frame on her fireplace mantel and had the Notification of Parents Rights poster in a binder, but does not have the Emergency Disaster Plan or the Child Passenger Safety Law.

Pets: Licensee has two dogs, one Pitbull and one Shih-Tzu. They were observed to be kept behind a chain link fence in the backyard. Licensee states that is where the dogs remain at all hours of the day, not just during daycare hours. Licensee was advised to obtain the vaccination records of the dogs.

Fire safety: Licensee has a fire extinguisher, size 3-A:40-B:C, which is mounted in the pantry in the kitchen. It was last serviced 03/05/19. Licensee keeps a fire drill log. The last fire drill was logged on April 19, 2019, but no time was listed. There is a smoke detector in the "sick room" and in the room where daycare is provided; both were tested and are operable. There are also two smoke detectors in the hallway between the downstairs bedrooms and the bathroom; as they are electrically wired, they were not tested. There is a carbon monoxide detector mounted in the kitchen; it was tested and is operable. There is a screen in front of the fireplace in the dining room.

Transportation: As Licensee offers transportation, both of her vehicles were inspected during today's visit. All seatbelts were operable.
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 198013326
VISIT DATE: 07/02/2019
NARRATIVE
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and the room and the bathroom used by the daycare children and (outdoors): the backyard.

The areas which have been designated off-limits were not inspected: the living room and upstairs. The stairs leading upstairs is barricaded by a baby gate at the bottom of the stairs; the living room is not rendered inaccessible. Though licensee stated that the converted garage is off-limits, it was not rendered inaccessible. The "extra room" smelled of paint and licensee thus locked it, rendering it inaccessible.

Physical Plant: The residence was inspected for safety, comfort, cleanliness, telephone service (licensee has a cell phone and a landline), heating and ventilation (there is a ceiling fan in each bedroom and there is central heating and air-conditioning), inaccessibility to poisons, detergents, cleaning compounds (kept in the cabinet above the refrigerator and in the garage,) medicine (none observed) and hazardous items that can pose a danger to children (e.g. the knives are also kept in the cabinet above the refrigerator).

Toys and napping equipment: There are age-appropriate toys and napping equipment on the premises. Licensee has two playpens, one crib and 28 mats and one cot. The children nap in both the daycare room and in the "sick room." In addition, licensee has several couches in the dining room that the daycare children can sleep on.
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 198013326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2019
Section Cited
HSC
1597.622(a)(1)
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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.
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Licensee stated that she will obtain verification of influenza for all four staff and verification of immunity to measles or ertussis for Staff #1 and #2 by the POC due date of 08/01/19. Verification will be provided to CCL via e-mail, fax, or mail.
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-This requirement is not met as evidenced by: one of the four staff files reviewed contained a current influenza vaccination or declination. Further, the files of Staff #1 & #2 do not contain verification of immunity to measles or pertussis. *This poses a potential risk to the health and safety of the children in care.*
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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: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019
LIC809 (FAS) - (06/04)
Page: 7 of 7