198017999-7-14-2023-54-CC-AESA-CTQV8G-20230714161243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198017999
Report Date: 07/14/2023
Date Signed: 07/14/2023 04:12:57 PM

Document Has Been Signed on 07/14/2023 04:12 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:	KUYPER FAMILY CHILD CARE		FACILITY NUMBER:	198017999
ADMINISTRATOR:	KUYPER, REBECCA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 370-4841
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	14	CENSUS: 10	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Licensee Rebecca Kuyper		TIME COMPLETED:	04:25 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 Rebecca Kuyper 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 10 children and 3 additional staff present at the time of 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 12 years old and operation days/ hours are Monday through Friday 6:00AM to 6:00PM. This is a one-story home which consists of three bedrooms, two bathrooms, kitchen, living room, den, garage, front yard (not fenced) and backyard (fenced). On limit areas include the living room, kitchen, two bedrooms, den and backyard. The bedroom that leads to the den is used as a pass through. Areas off limits to children include 1 bedroom, 1 bathroom, and garage. The children use the bathroom in the hallway. 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 living 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 6/1/23. 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). LPA observed a purchase receipt dated 7/7/23. The home maintains telephone service (mobile). LPA observed cleaning compounds and sharp objects such as knives located in the kitchen area inaccessible to children in care. Per Licensee, no children require medication. Per Licensee there are no poisons stored in the home. LPA advised Licensee that all poisons must be locked

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 9813362
LICENSING EVALUATOR NAME: Austin Estrada	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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: KUYPER FAMILY CHILD CARE	FACILITY NUMBER: 198017999
	VISIT DATE: 07/14/2023

NARRATIVE

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away, not only inaccessible. Isolation area for sick children waiting to be picked up is in the living room, away from the other children. Per Licensee there are no firearms or weapons stored in the home.
Food is provided by 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. Appropriate sleeping arrangements (mats) were observed.
The outdoor play area was observed to be fenced and contain toys and other age- appropriate materials available for children. LPA observed the side of the backyard to be fenced and off limits to children in care. Per Licensee, children are supervised while playing outside. LPA did not observe any pools, spas, or other bodies of water. During the inspection, children present were observed to be treated with dignity and respect, observed to be receiving safe, healthful, and comfortable accommodations, furnishings, and equipment, 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 LPA 3 out of 4 staff not to have immunization records for measles, pertussis, or tuberculosis. LPA advised Licensee that immunization records for staff should be available for review.
Infant Care: Currently Licensee cares for 1 infant. LPA also observed 2 play yards and 2 cribs available for use.
LPA reviewed Safe sleep regulations with Licensee, including LIC 9227 (Infant Sleep Plan) for infants under 12 months and 15-minute sleep check documentation for infants 0-24 months. LPA 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.
Overnight Care: Per Licensee, there is no overnight care is not provided.
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

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 9813362
LICENSING EVALUATOR NAME: Austin Estrada	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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: KUYPER FAMILY CHILD CARE	FACILITY NUMBER: 198017999
	VISIT DATE: 07/14/2023

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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: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 07/14/2023 04:12 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: KUYPER FAMILY CHILD CARE	FACILITY NUMBER: 198017999
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) 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. 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 in 3 out 4 staff did not have immunization records for measles, pertussis, or tuberculosis which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Licensee will provide proof of immunization records for measles, pertussis, and tuberculosis for staff to LPA via email by POC due date.

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: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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