198017716-4-6-2023-33-CC-JMOA-CQMTUW-20230406150302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198017716
Report Date: 04/06/2023
Date Signed: 04/06/2023 03:03:23 PM

Document Has Been Signed on 04/06/2023 03:03 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	THEUS FAMILY CHILD CARE		FACILITY NUMBER:	198017716
ADMINISTRATOR:	THEUS, SHERRIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 798-3878
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	14	CENSUS: 8	DATE:	04/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Sherrie Theus		TIME COMPLETED:	03:20 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) Judy Mora conducted an unannounced annual required inspection at the above facility on 04/06/23 at 01:25 AM. LPA met with Sherrie Theus, Licensee, who guided LPA on a tour of the home. Licensee's assistant, Deborah Johnson, was also present. There were eight children present at the time of arrival. The Licensee is the only adult living in the home (criminal record clearance on file). All areas identified on the facility sketch were inspected. This is a single story home which consists of 3 bedrooms, 1 bathrooms, living room and kitchen. The children use the bathroom, rear bedrooms and living room. Children use the back yard, which is fully fenced for outdoor play. There is a fire place in the living room which is inaccessible. Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There are toys available for children. There is central air and heating in the home. There is a working telephone service maintained in the home. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible. Smoke and carbon monoxide detectors are present in the home. Fire extinguisher indicates fully charged, last service 04/14/22. All food is prepared by the Licensee. The Licensee does not provide transportation services. LPA observed the following required posted documentation: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form. LPA reviewed facility records for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, the licensee has not conducted a drill in the last 6 months; this is a potential risk to the health and safety of children in care. Licensee states there are currently 08 children enrolled, children's roster was reviewed. *REPORT CONTINUES ON NEXT PAGE

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy Mora	TELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: THEUS FAMILY CHILD CARE	FACILITY NUMBER: 198017716
	VISIT DATE: 04/06/2023

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
26
27
28
29
30
31
32

Licensee states that there are no poisons stored in the home and understands that all poisons must be locked, not only inaccessible to children. Licensee states she uses the back room in case a child becomes sick. Per Licensee there are no firearms or weapons stored in the home.

Infant Care: The facility currently has two infant under 12 months. LPA observed the sleeping equipment for each child. LPA informed licensee of the Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's 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).

Staff records were reviewed for approved Pediatric First Aid and CPR certification, Licensee and Assistant have current Pediatric First Aid and CPR which expires 02/2025. LPA reviewed the LIC 508- Criminal Record Statement, Proof of immunization's against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate, certificates were not available.

Incidental Medical Services (IMS) policy was discussed. Per Licensee there are no children on medications. 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

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.

*REPORT CONTINUES ON NEXT PAGE

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy Mora	TELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

Page: 2 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: THEUS FAMILY CHILD CARE	FACILITY NUMBER: 198017716
	VISIT DATE: 04/06/2023

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
26
27
28
29
30
31
32

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 https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. 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 fees are not current.

Based on LPA's observations and records review, the following deficiency listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiency that is 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. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Licensee, Sherrie Theus.

*END OF REPORT

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy Mora	TELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 04/06/2023 03:03 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: THEUS FAMILY CHILD CARE	FACILITY NUMBER: 198017716
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) 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. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above, the licensee has not conducted a drill in the last 6 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/13/2023
	Plan of Correction
1 2 3 4	Licensee state she will conduct a drill next week and send LPA a copy of the drill.

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: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy Mora	TELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6