198020093-8-6-2021-54-CC-AJLO-C5MPJU-20210806112209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020093
Report Date: 08/06/2021
Date Signed: 08/06/2021 11:22:22 AM

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:	ALLEN FAMILY CHILD CARE		FACILITY NUMBER:	198020093
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 3	DATE:	08/06/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Keisha Allen, Licensee		TIME COMPLETED:	11:45 AM

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	Visit Conducted in English An unannounced Required One Year Inspection was conducted by Licensing Program Analyst (LPA) A. Lucero. LPA met with licensee Keisha Allen who guided LPA on a tour of the facility. This is a single story, three bedroom, two bathroom home. Adults residing in the home were discussed, noted and checked for fingerprint clearance. No other adults were present at the time of inspection. Areas accessible to children were inspected as follows: Formal dining area that has been converted into a day care area, one bedroom, one bathroom in hallway, and back yard. Areas off limits include: Living room, dining area, den, two bedrooms, master bath, front yard and attached garage. Licensee stated that there are no weapons or firearms on the premises. LPA did not observe swimming pools or spas on the premises. The backyard is adequately fenced. There are age appropriate toys and equipment on the premises. The smoke detectors and carbon monoxide detectors are present in the facility and in operable condition. Fire extinguisher is present in the home. CPR/First Aid Card: National CPR Foundation taken on 08/09/2020 and valid for two years. However, the card provided does not have EMSA Certified Stickers. Child Care Roster, Disaster Plan, and Children's Records were reviewed and discussed. Children records and required licensing forms were discussed as well as mandated child abuse reporting and criminal record clearance requirement.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

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: ALLEN FAMILY CHILD CARE	FACILITY NUMBER: 198020093
	VISIT DATE: 08/06/2021

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

The following was discussed with the Licensee:

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. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

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 adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.

A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License shall 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. 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.

Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. 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.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: ALLEN FAMILY CHILD CARE	FACILITY NUMBER: 198020093
	VISIT DATE: 08/06/2021

NARRATIVE

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Baby walkers, saucer chairs, bouncers or any similar items are prohibited. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed. LPA provided a complete packet of the Provider Information Network (PIN) 10-02-CCP dated February 20, 2019 regarding Safe Sleep Awareness Campaign during today’s inspection.

All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

· Dog(s) and/or pets should be isolated from children in care.
· It is recommended that First-Aid kits be available on premises.
· Outdoor supervision required at all times. If outdoor area not adequately fenced, provider must be with children at all times when outdoors.

These forms may also be downloaded from our website: www.ccld.ca.gov

See deficiencies page for deficiencies cited during today's visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1

Exit interview, copy of report was given. Appeal rights were issued and discussed.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: ALLEN FAMILY CHILD CARE	FACILITY NUMBER: 198020093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/06/2021 Section Cited	1 2 3 4 5 6 7	Personnel Requirements 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.
	8 9 10 11 12 13 14	The requirement is not met as evidenced by: During review of records, LPA determined that the CPR/First Aid course taken is not EMSA certified. This is a potential risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Armando J Lucero	TELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

LIC809 (FAS) - (06/04)

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