198014088-1-10-2020-54-CC-SSAZ-BKPVBE-20200110151726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198014088
Report Date: 01/10/2020
Date Signed: 01/10/2020 03:17:34 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	SHACK FAMILY CHILD CARE		FACILITY NUMBER:	198014088
ADMINISTRATOR:	SHACK, FELICIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 639-3443
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY:	14	CENSUS: 0	DATE:	01/10/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Felicia Shack, Licensee		TIME COMPLETED:	03:35 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) Susann Sanchez conducted an unannounced random inspection to the above facility. LPA met with Felicia Shack, Licensee who guided analyst on a tour of the facility. The licensee states that she currently has 0 children enrolled. Licensee was on inactive status from June 10, 2019 to Jan 06, 2020. Hours of operation 7:30 to 5:00pm. This is a two-story home which consists of 4 bedrooms, 4 bathrooms, kitchen, dining room, living room, office, preschool room, backyard, garage and front yard. The children use the bathroom that is connected to the pre-school room. Per licensee, areas off limits to children and parents include: all upstairs, all bedrooms, garage, kitchen, dining room, living room , and 3 restroom and front yard. The licensee provides food for children in care. The licensee states that 4 adults and 0 children currently live in the home. 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. All areas identified on the facility sketch that children use, were inspected for safety, comfort, cleanliness, telephone service, ventilation and heating (central). The following was observed and reviewed during this inspection. PHYSICAL PLANT Detergents, cleaning compounds, medications, and other items which could pose a danger are inaccessible to children. Cleaning compounds are kept locked in the an off limit hallway.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SHACK FAMILY CHILD CARE	FACILITY NUMBER: 198014088
	VISIT DATE: 01/10/2020

NARRATIVE

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The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 12/17/2019, 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 has completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 05/11/2021. There are first aid supplies available. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. The licensee has not conducted a fire drill in the last six months due to being in inactive status.

The home is observed to be clean and orderly. There is heating and ventilation for safety and comfort. . There are toys available for children. The licensee states that there is a land line on the premises and the licensee states that a cell phone is used and stays at the facility during operating hours.

The outdoor play area was observed to be fenced. At this time, children are using the back yard for outdoor play time. The licensee states that supervision is provided at all times.

PETS: There is a small dog in the house.
POSTING REQUIREMENTS: Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are observed to be posted in the entrance of the preschool room.
PROHIBITED: 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. DO NOT SLEEP CHILDREN IN CAR SEAT. SMOKING IS PROHIBITED IN A LICENSED FAMILY CHILD CARE HOME.

Infant Care: Licensee states that she will not care for infants at this time. 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 Patent’s Rights Poster with Complaint Hotline information, Never Shake a Baby, Sudden Infant Death Syndrome (SIDS), and Safe Sleeping practices.

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SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SHACK FAMILY CHILD CARE	FACILITY NUMBER: 198014088
	VISIT DATE: 01/10/2020

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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.

H&S 1597.622: 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. The licensee does have proof of immunization against influenza, pertussis, and measles.

Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. (use LIC624B for written report). Licensees shall reveal each facility license number in all advertisements, publications, or announcements made with the intent to attract clients.

At this time, the licensee is in compliance with California Code of Regulations Title 22. No deficiencies cited. LPA will let LPM know that Licensee is ready to operate and be removed from Inactive Active status. At this time, LPA conducted and annual inspection.

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. Failure to maintain posting as required will result in a civil penalty of $100.00.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020

LIC809 (FAS) - (06/04)

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