198016464-6-6-2023-54-CC-AESA-CSJTH9-20230606144421

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198016464
Report Date: 06/06/2023
Date Signed: 06/06/2023 02:44:32 PM

Document Has Been Signed on 06/06/2023 02:44 PM - 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 S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	VAN LEEUWEN FAMILY CHILD CARE		FACILITY NUMBER:	198016464
ADMINISTRATOR:	VAN LEEUWEN, TRINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 522-5192
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	14	CENSUS: 11	DATE:	06/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Trina Van Leeuwen, Licensee		TIME COMPLETED:	01:30 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) Austin Estrada conducted an unannounced required 1-year inspection at the above facility. LPA met with the Licensee Trina Van Leeuwen and informed her of the purpose for the visit. LPA provided the inspection Entrance Checklist (LIC 126). Licensee guided LPA on a tour of the facility. There were 11 children and one assistant present during the inspection. All adults present during the inspection have obtained a criminal record clearance or exemption. Individuals residing in the home have been discussed and noted. Licensee provides care to children ages newborn to five years old and operation days/ hours are Monday through Friday 6:00 AM to 6:00 PM. This is a one-story home which consists of two bedrooms, one bathroom, kitchen,dining room, day care room (near kitchen), living room, detached garage front yard and backyard (fenced). Per Licensee off limits areas include two bedrooms. On limits areas include the living room, day care room, dining room, kitchen, backyard, garage, and bathroom. The bathroom is located in the hallway and the bathroom was observed to be safe and sanitary. All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection: LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. All documents were observed to be posted in the daycare room. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610A- Emergency Disaster Plan and Verification of Disaster and Fire Drills. The last drill was conducted on 5/17/23. All documents were observed during the inspection. There is an operable carbon monoxide detector and a smoke detector in the home. A fully charged Fire extinguisher (2A10BC) was observed and last serviced on 8/18/22. The home maintains telephone service (landline/mobile). LPA observed cleaning compounds in the kitchen area inaccessible to children in care. LPA observed sharp objects such as knives located on the kitchen counter accessible to children in care. LPA advised Licensee that sharp objects such as knives should be made inaccessible to children in care.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 9813362
LICENSING EVALUATOR NAME: Austin Estrada	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: VAN LEEUWEN FAMILY CHILD CARE	FACILITY NUMBER: 198016464
	VISIT DATE: 06/06/2023

NARRATIVE

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Licensee immediately removed the knives to an inaccessible area of the kitchen.
Per Licensee there are no poisons stored in the home. LPA advised Licensee that all poisons must be locked away, not only inaccessible. Isolation area for sick children waiting to be picked up is in the kitchen, away from the other children. Per Licensee there are no firearms or weapons stored in the home.
Food is provided by the Licensee. LPA advised Licensee if children bring food from home, it must be labeled with the child’s name and properly stored or refrigerated.
The home is observed to be clean and orderly. There are toys and other age-appropriate materials available for children. LPA observed sleeping cots in the daycare room available for children. Per Licensee, sheets are provided and washed weekly at the facility. LPA observed wall heaters located in the hallway and living room. Wall heaters were observed to be inaccessible to children.
The outdoor play area was observed to be fenced and contain toys and other age- appropriate materials available for children. Per Licensee, children are supervised while playing outside. LPA observed the outdoor area to have two separate off-limits areas. Both off limits areas were separated by a fence and made inaccessible to children in care. One off limits area in the backyard was made for the Licensees pet cats. Per Licensee there are four cats that she provides care to. LPA also observed the back portion of the backyard to be made inaccessible to children in care. LPA observed the garage to be accessible to children in care. LPA advised Licensee that it is best practices to have pets current on immunizations. The garage was observed to be safe and obtain age-appropriate toys for children in care. Per Licensee no children eat or sleep in the garage. LPA did not observe any pools, spas, or other bodies of water. During the inspection, children present was observed to be treated with dignity and respect and free from corporal and/or unusual punishment.
Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months). All records were observed to be complete.
Personnel records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, and LIC 9108- Statement of Child and Mandated Reporter Training Certificate. Licensee’s and assistants CPR/First Aid expire on 2/18/25. LPA did not observe a current mandated reporter training certificate for the Licensee. LPA advised Licensee that the mandated reporter training should be completed every two years.
Infant Care: Currently Licensee cares for 2 infants. LPAs observed two play yards in the living room. LPA

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 9813362
LICENSING EVALUATOR NAME: Austin Estrada	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: VAN LEEUWEN FAMILY CHILD CARE	FACILITY NUMBER: 198016464
	VISIT DATE: 06/06/2023

NARRATIVE

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observed each infant to have their own play yard and to be sleeping with no loose objects in the crib. LPA observed an infant sleep log for both infants.
Overnight Care: Per Licensee, overnight care is not provided.
LPA provided and discussed PIN 23-06-CCP Information Regarding Brightly Colored Fentanyl, Also Referred to as “Rainbow Fentanyl”.
Incidental Medical Services (IMS): 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm
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.
LPA advised Licensee that all adults age 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.
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, interviews and records review, the following deficiencies listed on the attached LIC 809D (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. Deficiencies include one type B violation.
An exit interview was conducted, and report was reviewed with Licensee. A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty. Appeal rights were discussed and provided to the Licensee.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 9813362
LICENSING EVALUATOR NAME: Austin Estrada	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/06/2023 02:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK S WEST, 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: 06/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102423(a)(2)

Personal Rights

(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above: LPA observed knives on the kitchen counter accessible to children in care, which posed a potential health, safety or personal rights risk to persons in care. Licensee immediately removed the knives to an inaccessible area of the kitchen
	POC Due Date: 06/06/2023
	Plan of Correction
1 2 3 4	Licensee will keep knives inaccessible to children in care. Licensee immediately placed the knives in an inaccessible area of the kitchen.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Valarie Cook	TELEPHONE: (323) 9813362
LICENSING EVALUATOR NAME: Austin Estrada	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC809 (FAS) - (06/04)

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