198019959-10-8-2019-54-CC-SSAZ-BGRR8L-20191008124806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198019959
Report Date: 10/08/2019
Date Signed: 10/08/2019 12:48:21 PM

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:	MACK FAMILY CHILD CARE		FACILITY NUMBER:	198019959
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	10/08/2019
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Myesha Mack, Licensee		TIME COMPLETED:	01:10 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 Analyst (LPA) Susann Sanchez conducted an unannounced case management inspection in regards to the licensee requesting a capacity increase. LPA met with Myesha Mack, Licensee who guided analyst on a tour of the facility. Per Licensee, family members residing in the home are 2 adults and 7 children. Licensee is requesting a large family child care home license. Per Licensee, operation hours will be Monday to Friday, 6:00AM to 6:00PM. Licensee states that she will care for children 0-12 years of age. All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a two story home that consists of 4 bedrooms, 2 restrooms, dining area, living room, day care room (den), kitchen, garage, backyard (split into two parts), and front yard. Per applicant, the children will use the restroom in the day care room, day care room, dining area, living room, and part of the backyard (the part that is connected to the day care room). Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating (central and inaccessible to children). Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible and are kept in high cabinets in the kitchen. Based on the Facility Sketch submitted, areas off limits to children and parents are: All of upstairs, garage, part of the backyard, and the front yard. There is a gate at the bottom of the stairs. All other off- limit area are locked and have a latch at the top of each door. The applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3439
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2019

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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: MACK FAMILY CHILD CARE	FACILITY NUMBER: 198019959
	VISIT DATE: 10/08/2019

NARRATIVE

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OUTDOOR PLAY AREA
The children will use the part back yard for outdoor play, which was observed to be fenced. There is also a gate blocking the other half of the backyard. Licensee states that children will be physically and visually supervised at all times.

PETS: Per applicant, there are no pets in the home.
BODIES of WATER: Per applicant, there are no bodies of water on the premises.
FIREARMS/WEAPONS: Per applicant, there are no fire arms or weapons on the premises.
There are toys available for children. The applicant states that they will provide food for children in care.

The value on the 2A10BC fire extinguisher indicates fully charged, and was serviced on 0826/2019. Smoke and carbon monoxide detectors were tested and are operable. The applicant has completed the required Health and Safety Training, Nutrition Training and Pediatric First Aid and CPR which expires 08/2020. There are first aid supplies available.

The following was discussed with the applicant:
Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Civil Penalties will be assessed if not in compliance.
· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training, Immunizations (TDAP, MMR, Influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.
· Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
· The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked and batteries replaced as needed.
· Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
· Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3439
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2019

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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: MACK FAMILY CHILD CARE	FACILITY NUMBER: 198019959
	VISIT DATE: 10/08/2019

NARRATIVE

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· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a family child care home.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
· No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility. Never sleep an infant in a car seat.
· Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
· The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.
· Isolation for Ill children: When a child is ill he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).
· Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information. At this time, Licensee does not have lability insurance.

· Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children have proof of immunizations.

· Mandated Reporter Training: H&S 1596.8662: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com

Infant Care: Licensee states that she is currently caring for one infants. LPA advised the applicant to sleep infants where they can be directly supervised at all times and advised against sleeping infants in a separate room. The applicant states the following as a supervision plan for infants: Licensee states that infants will sleep in the day care room where she will be providing supervision. Infant currently sleeps in a mat. LPA provided the applicant with a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. Online copy can be downloaded at: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3439
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2019

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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: MACK FAMILY CHILD CARE	FACILITY NUMBER: 198019959
	VISIT DATE: 10/08/2019

NARRATIVE

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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 applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms:

CHILDREN FORMS/RECORDS - Children’s files must contain the following documents/information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), Consent/Verification for Nebulizer Care (LIC 9166), California School Immunization Record, Parent Notification for Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Acknowledgment of Receipt of Licensing Reports (LIC 9224).
FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records: As required in Title 22 Regulations 102416.1, Unusual incident/Injury Report (LIC 624B): Child Care Facility Roster (LIC 9040), Notice of Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108), Property Owner/Landlord Consent (LIC 9149), Property Owner/Landlord Notification Form (LIC 9149).
INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by Law to post the following:
Facility License (LIC 203), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parent’s Rights (PUB 394). A Notice of Site Visit (LIC 9213): Must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3439
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2019

LIC809 (FAS) - (06/04)

Page: 4 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: MACK FAMILY CHILD CARE	FACILITY NUMBER: 198019959
	VISIT DATE: 10/08/2019

NARRATIVE

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OTHER INFORMATION AND FORMS PROVIDED:
· Handouts provided for Never Shake a Baby, Sudden Infant Death Syndrome (SIDS) and Safe Sleeping practices
· Capacity Handout for a Small Family Child Care Home and Large Family Child Care Home was provided.

Based on the LPA’s observation, there are no corrections to be made. LPA will submit application to LPM for final approval. Once licensed, the applicant is required to comply with the terms and limitations stated on the license. A copy of this report was reviewed and provided to the Licensee.

Exit interview conducted with licensee, Myesha Mack. Appeal Rights provided and explained. Notice of Site Visit must be posted for (30) days. Failure to do so may result in a $100.00 civil penalty.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3439
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2019

LIC809 (FAS) - (06/04)

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