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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016464
Report Date: 09/16/2021
Date Signed: 09/16/2021 05:35:56 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:VAN LEEUWEN FAMILY CHILD CAREFACILITY NUMBER:
198016464
ADMINISTRATOR:VAN LEEUWEN, TRINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 522-5192
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:14CENSUS: 9DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Trina Van LeeuwenTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Elka Chavez conducted an unannounced annual inspection to the above facility on 09/16/2021. LPA arrived at the facility at 1:05 PM and met with Licensee, Trina Van Leeuwen, Licensee who guided analyst on a tour of the facility. Also present during this inspection, was, Kenneth Van Leeuwen, Licensee’s Spouse. Entrance Checklist for Family Child Care Homes was provided to the licensee upon entry. Per Licensee, there are 11 children that are currently enrolled. A current children’s roster was available for review. There were 9 children present upon arrival.


This is a single-story home. The home consists of two bedrooms, one restroom, living room, play room, kitchen, back yard (fenced) and detached garage. Parents enter through the front door or side medal gate. Care is mainly provided in the play room adjacent to the kitchen. The two bedrooms are also used for napping and additional activity space. The living room and kitchen are accessible. Areas accessible to children are: Living room, day care room, two bedrooms, bathroom, backyard (fenced) and detached garage.
Areas off limits to children and parents are: The front yard, the off-limits area of the backyard is made inaccessible with a black fence. The garage is being used as additional activity space. Licensee was reminded no eating or sleeping is permitted in the garage. The licensee understands that licensing staff may have access to off-limit areas during inspection visit if necessary. **Rooms that are off-limits need to be made inaccessible during operating hours**


Individuals who reside in the home were noted and discussed. Per Licensee, they currently have one assistant. All adults present in the home have obtained a criminal record clearance. Licensee states that there are no firearms stored in the home.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Elka ChavezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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 6
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: VAN LEEUWEN FAMILY CHILD CARE
FACILITY NUMBER: 198016464
VISIT DATE: 09/16/2021
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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 landline and cell phone that is used, and the cellphone stays at the facility during operation hours. Safe toys play equipment and materials were observed.
Detergents, cleaning compounds, medications, and other items which could pose a danger to children were
observed to be inaccessible to children. 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. The restroom that children use was observed to be safe and sanitary.

The valve on the required 2A10BC fire extinguisher indicates fully charged and was serviced on 08/23/21, as indicated on service tag. Smoke and carbon monoxide detectors were tested and are operable.

Licensee states that she is currently caring for 1 infant. Licensee states that the infant sleeps in a play yard located in the bedroom next to the bathroom. Appropriate sleeping arrangements were observed. Licensee was advised cribs or play yards cannot hinder the entrance or exit from the sleeping space, mattresses shall be firm and covered with a fitted sheet that overlaps the underside, so it cannot be dislodged. Licensee was advised cribs and play yards must be free of loose articles and objects. LPA did not observe any infants swaddled while in care. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age. A copy of the LIC 9227 was provided to Licensee. LPA provide Licensee with a copy of PIN 20-24-CCP - Recently Approved Safe Sleep Regulations In Effect.

Currently, children are using the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that can pose a danger to children on the outdoor yard. The licensee states that supervision is always provided.

The licensee is observed to be operating within the license capacity limitations. LPA did not observe any children left in parked vehicles. Car seats shall only be used for transportation. LPA did not observe any children sleeping in car seats.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Elka ChavezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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: VAN LEEUWEN FAMILY CHILD CARE
FACILITY NUMBER: 198016464
VISIT DATE: 09/16/2021
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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 02/2023. There are first aid supplies available. LPA advised that if a child shows signs of illness he/she/they shall be separated from other children.

LPA observed that the Licensee and assistant have a current Mandated Reporter AB 1207 Compliant Child Care Training Certificate on file. LPA issued a technical violation.

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 8/11/21.



There are 2 cats on the premises. LPA did not observe any pools, spas, hot tubs, fish ponds, or similar bodies of water during the inspection. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories are not permitted in a family child care facility. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] 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.

SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Elka ChavezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: VAN LEEUWEN FAMILY CHILD CARE
FACILITY NUMBER: 198016464
VISIT DATE: 09/16/2021
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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

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.


Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Trina Van Leeuwen.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Elka ChavezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: VAN LEEUWEN FAMILY CHILD CARE
FACILITY NUMBER: 198016464
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview and record review, the licensee did not comply with the section cited above in 9 out of 1 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2021
Plan of Correction
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Licensee will have the child's parent complete and sign the form tomorrow. LPA provided Licensee with a copy of PIN #20-24 CCP and Safe Sleep Frequently asked questions. Licensee will review the packet with Safe Sleep Frequently asked questions.
Type B
Section Cited
CCR
102425(c)(1)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This plan shall be signed and dated by the infant’s authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 9 out of 1 persons in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2021
Plan of Correction
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Licensee will have child #8 's parent complete and sign the LIC 9227 form tomorrow morning and provide a copy to LPA. LPA provided Licensee with a copy of PIN #20-24 CCP and Safe Sleep Frequently asked questions. Licensee will review the packet with Safe Sleep Frequently asked questions.
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: Karen ChambersTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Elka ChavezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: VAN LEEUWEN FAMILY CHILD CARE
FACILITY NUMBER: 198016464
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Licensee will have child #8 's parent complete and sign the LIC 9227 form tomorrow morning and provide a copy to LPA. LPA provided Licensee with a copy of PIN #20-24 CCP and Safe Sleep Frequently asked questions. Licensee will review the packet with Safe Sleep Frequently asked questions.
POC Due Date: 09/17/2021
Plan of Correction
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Licensee will have child #8 's parent complete and sign the LIC 9227 form tomorrow morning and provide a copy to LPA. LPA provided Licensee with a copy of PIN #20-24 CCP and Safe Sleep Frequently asked questions. Licensee will review the packet with Safe Sleep Frequently asked questions.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Karen ChambersTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Elka ChavezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6