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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019682
Report Date: 06/21/2022
Date Signed: 06/21/2022 12:16:05 PM


Document Has Been Signed on 06/21/2022 12:16 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 CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:BELGER FAMILY CHILD CAREFACILITY NUMBER:
198019682
ADMINISTRATOR:OLIVIA ADDIE BELGERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 423-5017
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY:14CENSUS: DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Licensee - Olivia BelgerTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) R. Derraco conducted an unannounced required one year inspection to the above facility on 06/21/22. LPA arrived at the facility at 9:05 Am and met with Licensee Olivia Belger who guided analyst on a tour of the facility. Also present during this inspection was an assistant, S2. Per Licensee, there are 14 children that are currently enrolled. There were 11 children present upon arrival.

This is a one-story home which consists of 3 bedrooms, 2 bathrooms, kitchen/dining room, 2 living rooms, a detached garage, front yard and backyard (fenced). The off limit areas include all 3 bedrooms, 1 bathroom, the garage, part of the backyard play area, and the kitchen

The main care area is located in the front living room. LPA observed age appropriate toys, a wall mounted television, a pull down fire alarm, child sized tables, child sized chairs, a storage locker for toys and baby gates separating the hallway and the dining area. The dining area was observed to have additional age appropriate toys, art supplies, and cushioned floor mats. Licensee states that the dining area is used to separate her younger children from the older children. LPA observed another baby gate leading into the off-limits kitchen. LPA observed additional cleaning supplies to be locked and kept underneath the off limits kitchen sink. The licensee states that she provides food for children in care. LPA observed the bathroom designated for children in care to have an operable sink and toilet. Cleaning supplies were observed to be locked underneath the bathroom sink. Per licensee, the tub is currently being used as a storage area. The living room located in at the rear of the home is currently being used as a napping room for children in care. LPA observed two wooden cribs, a play pen, sleeping cots, and a baby changing station. The backyard play area was observed to have perimeter fencing. An off-limits detached garage was observed in the backyard play area and made inaccessible by sheet of wood covered with a blanket. A white fence was also observed to separate the off-limits section of the backyard play area. An off-limits storage shed was observed towards the back of the play yard. LPA observed a baby gate in place of the missing door of the
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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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 12


Document Has Been Signed on 06/21/2022 12:16 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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: BELGER FAMILY CHILD CARE
FACILITY NUMBER: 198019682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2022
Plan of Correction
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LPA will make a case management visit to observe corrections after 07/11/22
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2022
Plan of Correction
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LPA will make a case management visit to observe corrections after 07/11/22

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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 12


Document Has Been Signed on 06/21/2022 12:16 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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: BELGER FAMILY CHILD CARE
FACILITY NUMBER: 198019682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2022
Plan of Correction
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LPA will make a case management visit to observe corrections after 07/11/22
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2022
Plan of Correction
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LPA will make a case management visit to observe corrections after 07/11/22

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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 12


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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: BELGER FAMILY CHILD CARE
FACILITY NUMBER: 198019682
VISIT DATE: 06/21/2022
NARRATIVE
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storage shed. Per licensee, the baby gate is temporary until she is able to properly fix the storage shed door. Outdoor play equipment for children and a portable sink was also observed in the backyard play area. Wall heaters were observed to have covers making it inaccessible for children in care. Per licensee, isolation area for children showing signs of illness will be located in the main care area next to the front door.

Individuals who reside in the home were noted and discussed. 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. Licensee states that there are no firearms stored in the home.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety,


comfort, and cleanliness. Licensee was advised to send an updated facility sketch to LPA indicating areas that are currently off limits. There is telephone service via a land line. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked, not just inaccessible. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 05/10/22, as indicated on service tag. Smoke and carbon monoxide detectors were tested and are operable. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs. No bodies of water were observed in the back yard play area. There are no pets on the premises. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

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.

The licensee and other personnel have completed training on preventive health practices including Pediatric
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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
Page: 11 of 12
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: BELGER FAMILY CHILD CARE
FACILITY NUMBER: 198019682
VISIT DATE: 06/21/2022
NARRATIVE
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First Aid and CPR. The licensee's Pediatric First Aid and CPR expires in 04/2023. LPA observed that the Licensee and assistant do have proof of the Mandated Reporter AB 1207 compliant Child Care Training Certificate on file. File review was observed to not have proper mandated immunization records. LPA advised licensee that a citation under Health and Safety Code (HSC) section 1597.622(c) will be issued. Children’s records were reviewed. LPA observed emergency information cards and immunization records to be missing for 4 children in care. LPA advised licensee that a citation under California Code of Regulation (CCR) sections 102417(g)(7) and 102418(g) will be issued. A current children’s roster was available for review, however the roster was incomplete and not updated. LPA advised licensee that a citation under CCR section 102417(g)(8) will be issued

Incidental Medical Services (IMS):
IMS was discussed with licensee. Per licensee, there are no children enrolled that require IMS at this time. 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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA advised the licensee to access forms, regulations and quarterly updates online at: www.cdss.ca.gov. LPA also discussed and provided the Provider Information Notices (PINS) on Recently Approved Safe Sleep Regulations in Effect: PIN 20-24-CCP, Licensee's, Children's and Assistant File Checklist.

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, appeal rights provided, and report was reviewed with the licensee Olivia Belger.


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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Randy DerracoTELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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