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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019046
Report Date: 10/12/2023
Date Signed: 10/12/2023 04:19:18 PM


Document Has Been Signed on 10/12/2023 04:19 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 CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:LAM FAMILY CHILD CAREFACILITY NUMBER:
198019046
ADMINISTRATOR:LAM, KELLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 215-7147
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:14CENSUS: 1DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Kelly Lam, LicenseeTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPAs) Thelma Razo and Shushanik Safaryan conducted an unannounced Required – 1 Year inspection at the above facility on 10/12/23 at 9:01am. A COVID 19 risk assessment was conducted prior to entering the facility. Licensing staff met with Licensee Kelly Lam and boyfriend Dung Tran who helped with translations and guided analysts on a tour of the facility. LPA provided a copy of Entrance Checklist—Family Child Care Home (LIC126) to licensee. There was one child present during this inspection. Facility capacity is in compliance for a Large Family Child Care Home. Per licensee, there were eleven children currently enrolled. Hours of operation are Monday-Sunday 7:00 AM - 10:00 PM.

This is a single-story home which consists of 3 bedrooms, 2 bathrooms, kitchen, living room, dining room attached garage and backyard. Children have access to all areas with the exception of master bedroom with private bathroom, attached garage and backyard. Currently residing in the home are 2 adults and no minor children.

LPA observed the following required posted documentation in the main entry way of the facility: Facility License, Publication (PUB) 394- Notification of Parent Rights
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SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Thelma RazoTELEPHONE: (323) 981-3387
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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 CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LAM FAMILY CHILD CARE
FACILITY NUMBER: 198019046
VISIT DATE: 10/12/2023
NARRATIVE
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and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA reviewed facility records for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan. LPA observed disaster drill conducted on May of 2023.

The home was observed to be clean and orderly, with air and heating. LPAs observed the smoke detector and the carbon monoxide detector to be in operable condition. Licensing staff observed the valve on the required 2A 10BC fire extinguisher indicates fully charged and last service on 9/5/2018. LPA reminded licensee fire extinguisher should be serviced yearly. The home maintains telephone service via cell phone. There are toys and other age-appropriate material available for children. Licensee prepares meals and snacks. LPA observed a first aid kit in the facility.

Licensee states that there are no poisons stored in the home and understands that all poisons must be locked, to be made inaccessible to children. Per Licensee there are no firearms or weapons stored in the home. Licensing staff reminded licensee smoking is not allowed in the home.

The Licensee stated that she is not using the back yard for outdoor play. The outdoor play areas were observed to be fenced.



Child’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, and LIC 995A Notification of Parents’ Rights.

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SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Thelma RazoTELEPHONE: (323) 981-3387
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LAM FAMILY CHILD CARE
FACILITY NUMBER: 198019046
VISIT DATE: 10/12/2023
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Licensee file was reviewed for the following: LIC 508- Criminal Record Statement, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse. Pediatric First Aid and CPR certification on expired 2021.

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 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Thelma RazoTELEPHONE: (323) 981-3387
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
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 CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LAM FAMILY CHILD CARE
FACILITY NUMBER: 198019046
VISIT DATE: 10/12/2023
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Licensee is to submit an updated facility sketch with dimensions and off limits indicated.

Based on Licensing staff observations and records review, the following deficiencies listed on the attached LIC 809D are being cited in accordance with California Code of Regulations Title 22.



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. Appeal Rights and report was reviewed with Kelly Lam.

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SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Thelma RazoTELEPHONE: (323) 981-3387
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/12/2023 04:19 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 CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: LAM FAMILY CHILD CARE
FACILITY NUMBER: 198019046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatio, the licensee did not comply with the section cited above , fire extinduisher was last serviced on 09/05/2018 as indicated in the service tag. This poses potential health and safety risk for children in care .
POC Due Date: 10/26/2023
Plan of Correction
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Licensee will service fire extinguisher and send the proof by the due date .
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses a potential health and safety risk to persons in care. Pediatric First aid and CPR was expired in 2020.
POC Due Date: 10/26/2023
Plan of Correction
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Licensee will register for the class and submit the proof to the LPA.
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: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Thelma RazoTELEPHONE: (323) 981-3387
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5