<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019922
Report Date: 10/18/2022
Date Signed: 10/18/2022 12:31:24 PM


Document Has Been Signed on 10/18/2022 12:31 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: 4DATE:
10/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Robin Henderson, LicenseeTIME COMPLETED:
12:50 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 Analysts (LPA) Susann Sanchez conducted an unannounced annual required inspection at the above facility on 10/18/22 at 10:25 PM. LPA met with Alanna Citizen, Licensee assistant who guided analysts on a tour of the facility. There were 2 children and 2 infants present when LPA arrived. Licensee Robin Henderson arrived at 10:40am and continued the tour. Facility capacity is in compliance for a large Family Child Care Home.

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

The licensee provides food for children in care: breakfast, lunch, and P.M. snacks. Hours of operation are Mon-Sun 12AM-11:57PM. 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.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption.

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. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on 6/15/22.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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 6


Document Has Been Signed on 10/18/2022 12:31 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: 10/18/2022

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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above. LPA observed fire extinguisher is fully charged, however, the service tag indicates that the fire extinguisher has not been serviced since 08/10/21 which poses a potential a safety risk to persons in care.
POC Due Date: 11/01/2022
Plan of Correction
1
2
3
4
 Licensee stated she will try again today 10/18/22 to get it serviced and made an appointment during inspection. Licensee will submit a photo via email to LPA via email by POC due date of 11/01/22.
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 CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6


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: 10/18/2022
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
26
27
28
29
30
31
32
Smoke and carbon monoxide detector were tested and are operable. The home maintains telephone service via cell phone. The home is observed to be clean and orderly. There age appropriate equipment, toys and material available for children. LPA observed that detergents, cleaning compounds, knives and medication are stored in the off limits kitchen and a locked storage in the hallway closet, inaccessible to children. Isolation area for sick children waiting to be picked up is in one of the off limit room or close off the living room, away from the other children. 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.

During tour at 10:30am, Fire Extinguisher is fully charged, however, the service tag indicates that the fire extinguisher has not been serviced since 08/10/21. Licensee showed proof that she tried to go to First Choice in Gardena to get it service but Fire Inspector was not there. Licensee stated she will try again today 10/18/22 to get it serviced and made an appointment during inspection.

LPA informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP . LPA provided Technical Assistance to licensee and staff. Licensee was documenting infant present (2) 15 minute sleep check but stopped when infants turned 1 because Licensee was confused and thought it was until 1 years old. LPA explained it was until 2 years old. Techinal violation was given.

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.



Consult was provided regarding overnight care. Licensee will like to start providing overnight care and the following was reviewed: Licensee is aware that they must remain awake while children are awake. If children sleep in separate area from licensee, the door must remain open. If licensee cannot hear children when they wake up, video or audio device can be used.

Currently children play in the backyard. There is a water pond that in the backyard that was observed to have covered and water is empty.

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: 10/18/2022
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
26
27
28
29
30
31
32
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 and, LIC 995A Notification of Parents’ Rights.

Staff records were reviewed for approved Pediatric First Aid and CPR certification which expires on 08/09/2023, 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 and current Mandated Reporter Training Certificate which expires on 08/15/2024.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

LPA observed that licensee is implementing COVID-19 precautions and procedures.

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 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.

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.

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: 10/18/2022
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
26
27
28
29
30
31
32
Based on the LPA's observations and records review the following deficiencies will be cited today in accordance with California Title 22 Regulations.

A notice of site visit was given and must remain posted for 30 days. Appeal Rights were given and explained. 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: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6