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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019530
Report Date: 04/06/2023
Date Signed: 04/06/2023 10:18:53 AM


Document Has Been Signed on 04/06/2023 10:18 AM - 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:CHANG & MONTEAGUDO FAMILY CHILD CAREFACILITY NUMBER:
198019530
ADMINISTRATOR:CHANG & MONTEAGUDOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 841-0505
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:14CENSUS: 12DATE:
04/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:David Chang TIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Judy Mora conducted an unannounced annual required inspection at the above facility on 04/06/23 at 8:35 AM. LPA met with David Chang, Licensee, who guided LPA on a tour of the home. Licensee's assistant's, Meiying Chang, Elliane Thong, and Nilanjana were also present. There were three children present at the time of arrival; additional children arrived during this visit.

Family members residing in the home are two adults (criminal record clearance on file). All areas identified on the facility sketch were inspected. This is a one story home which consists of 3 bedrooms, 2 1/2 bathrooms, kitchen, dining room, living room, recreation/play room, laundry room, storage room, office space(isolation area) garage, backyard and front yard. The children will use the recreation room, the living room, one bedroom, office space, dining room and 1 1/2 bathrooms. There is a fish tank in the living room which is inaccessible with a kiddie gate. There is also a fireplace (inaccessible) in the living room which has a kiddie gate to surround the area.

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 were tested and are operable. Fire extinguisher indicates fully charged, however, the last service was 01/28/19; this is a potential risk to the health and safety of children. 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, last drill documented was 04/03/23. Licensee states there are currently 14 children enrolled, children's roster was reviewed and is current.

*REPORT CONTINUES ON NEXT PAGE
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (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 5


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: CHANG & MONTEAGUDO FAMILY CHILD CARE
FACILITY NUMBER: 198019530
VISIT DATE: 04/06/2023
NARRATIVE
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Licensee states that there are no poisons stored in the home and understands that all poisons must be locked, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in the kitchen area. Licensee will use a playpen so children can rest. Per Licensee there are no firearms or weapons stored in the home.

Infant Care: The facility is caring for no infants under 12 months. The facility accepts infants at 14 months or older. 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. LPA reviewed sleep checks for infants present.

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). Children's records were observed to be complete.



Staff records were reviewed for approved Pediatric First Aid and CPR certification, Licensee and Assistant do not have current Pediatric First Aid and CPR. 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. The Licensee's certificates expired in 02/2023.

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 GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (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 5
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: CHANG & MONTEAGUDO FAMILY CHILD CARE
FACILITY NUMBER: 198019530
VISIT DATE: 04/06/2023
NARRATIVE
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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 webpagehttps://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.

Based on 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. 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, David Chang.

*END OF REPORT

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (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 5
Document Has Been Signed on 04/06/2023 10:18 AM - 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: CHANG & MONTEAGUDO FAMILY CHILD CARE
FACILITY NUMBER: 198019530

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023

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 LPA observation, the licensee did not comply with the section cited above. The fire extinguisher was observed to be fully charged, however, it has not been serviced since 2019 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2023
Plan of Correction
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Licensee states he will have the fire extinguisher serviced and send LPA a photo of the receipt and/or service tag.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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. It was observed that the Licensee's and the assistat't certificates expired in 02/23, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2023
Plan of Correction
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Licensee states he and all assistant's will take the training and send LPA copies.
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 GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (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 5


Document Has Been Signed on 04/06/2023 10:18 AM - 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: CHANG & MONTEAGUDO FAMILY CHILD CARE
FACILITY NUMBER: 198019530

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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. The Licensee's and assistant's certification expired in 02/23, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2023
Plan of Correction
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Licensee states they will take the Pediatric First Aid and CPR and send LPA a copy of the certification.
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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (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: 5 of 5