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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019922
Report Date: 07/10/2024
Date Signed: 07/10/2024 01:01:08 PM


Document Has Been Signed on 07/10/2024 01:01 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:HENDERSON FAMILY CHILD CAREFACILITY NUMBER:
198019922
ADMINISTRATOR:ROBIN HENDERSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 756-3137
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:14CENSUS: 6DATE:
07/10/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:ROBIN HENDERSON / LICENSEETIME COMPLETED:
01:15 PM
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Licensing Program Analysts (LPA's) Ashley Calderon and Susann Sanchez conducted an unannounced random / annual inspection at the above facility. At 9:43am LPAs observed a male walk into the facility. LPA met with assistant Alana Citizen who allowed LPAs entry to the facility. LPA's asked Ms.Citizen to confirm adults present, Ms. Citizen stated the Licensee's brother is present. Licensee Robin Henderson arrived at the facility and LPA explained the reason of today's visit. Hours of operation are Mon-Sun 12AM-11:57PM. Facility capacity is in compliance for a Large Family Child Care Home.

LPA's confirmed male adult with Licensee, Licensee stated that family member is visiting, and is not interacting with the children in care and is leaving shortly, deficiency cited and civil right penalty given for adult present with no fingerprint clearance. Licensee guided analysts on a tour of the facility.

This is a two level home with four bedrooms, three bathrooms, kitchen, dining area, living area, patio, day care room (garage), backyard, side and front yard. The children use: the bathroom in the hallway near the daycare room, living room, and backyard. Per licensee, areas off limits to children and parents include: upstairs and bedrooms located downstairs, front/side yards, dining area, and kitchen.

Kitchen was inspected, Licensee provides food for the children. Licensee was reminded if children bring food from home it must be labeled with the child’s name and properly stored or refrigerated. Living room was observed to have a fire place with a barricaded screen and a baby gate a the bottom of the stairway. 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,Notification of Parent Rights and Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on 4/10/24.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: HENDERSON FAMILY CHILD CARE
FACILITY NUMBER: 198019922
VISIT DATE: 07/10/2024
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Smoke and carbon monoxide detector were tested and are operable. The home maintains telephone service via cell phone. Fire Extinguisher is fully charged and serviced on 6/3/24. There facility has age appropriate equipment, toys and material available for children. LPA observed that detergents, cleaning compounds, knives and medication are stored in the off limit kitchen. Per Licensee there are no firearms or weapons stored in the home. The bathroom that children use was observed to be clean and free of hazards. Per Licensee facility does not have any pets in the home and no children are on medication.

LPA's reviewed staff and children records. Licensee mandated reporter training expires 8/15/24. Licensee's CPR and First Aid does not have a valid EMSA vendor and Licensee was unable to provide CPR/First for staff assistant who was present,deficiency cited. Children records were reviewed, Child #2 and #6 sleep log was not consistent for days child been present at the day care.

LPA's gave a Technical Advisory regarding sleeping accommodations. Licensee stated children nap in the garage because the garage is attached to the house. LPAs advised to use living room for sleeping arrangements. LPA's advised Licensee children and eating are not to be conducted in the living room unless permitted by the Fire Marshall's. LPA's consulted Licensee to call officer on duty when family visitors are present in the home for 3 days. Per Licensee, no poisons remain in the home, LPA's advise to lock poisons.

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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: HENDERSON FAMILY CHILD CARE
FACILITY NUMBER: 198019922
VISIT DATE: 07/10/2024
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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/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee.

The following deficiencies listed on the attached LIC 809-D (deficiency pages) are being cited in accordance with California Code of Regulations Title 22, Division 12, Chapter 1 and Section CCR & H&S. In addition, there was a civil penalty given LIC421-BG and appeal rights were provided.



During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Robin Henderson.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 07/10/2024 01:01 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: HENDERSON FAMILY CHILD CARE
FACILITY NUMBER: 198019922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(k)
Criminal Record Clearance
(k) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees, volunteers that require fingerprinting and non-client adults residing in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Calderon and Sanchez observated male adult entering the facility; LPA's reviewed personnel report individual was not cleared/ associated, Interview with Licensee and Staff Assistant present stated there is a visitor staying in the home, the licensee did not comply with the section cited above in [1] out of [1] persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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Licensee stated will fingerprint individual due to individual will possbily return to visit. Licensee will tell male indivudal to leave and stay with another family memeber. LPA's advised Licensee to avoid interaction with children when exiting.
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: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 07/10/2024 01:01 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: HENDERSON FAMILY CHILD CARE
FACILITY NUMBER: 198019922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation Licensee had sleep log for Child #2 and #6 , sleep log was dated June 3-7th, 2024, sleep log is inconsistant for days child is present at the facility, the licensee did not comply with the section cited above in [2] out of [2] [persons] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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Licensee will daily fill out sleep log when child #2 and #6 is present at the facility. Licensee will provide sleep log proof of sleep log records from today's date till poc due date by Poc 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 observation and records review LPA Calderon and Sanchez obvserved Licensee's CPR/First Aid that is not valid under Title 22 regulations, company used is not a EMSA vendor, and assistant did not have proof of CPR/ First Aid, the licensee did not comply with the section cited above in [2] out of [2] [persons] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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Licensee and assistant staff will conduct Pediatric First Aid and CPR, and will show proof of valid certification to LPA via text message by Poc due date.
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 CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5