198020244-5-8-2019-54-CC-TFIS-BBYU2D-20190508151146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020244
Report Date: 05/08/2019
Date Signed: 05/08/2019 03:12:15 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:	FERNANDO FAMILY CHILD CARE		FACILITY NUMBER:	198020244
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	05/08/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:58 PM
MET WITH:	Shamila Fernando		TIME COMPLETED:	03:25 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) Timothy Fields conducted a pre-licensing inspection today. LPA met with Applicants, Shamila and Tervine Fernando who guided analyst on a tour of the facility. Per applicant, family members residing in the home are three adults and one child. The applicant is requesting a small family child care home license. Per applicant, operation hours will be from 23 hours, seven days per week. Applicant states that they will care for children age 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 one story home that consists of three bedrooms, one and a half restrooms, dining room, living room, and kitchen Per applicant, Care will be provided in the living room. Applicants have children proof barriers isolating the dining room, kitchen, and hallway. One bedroom and half bathroom adjacent to the kitchen are accessible. The activity space used by children were inspected for safety, comfort, cleanliness, telephone service, ventilation, and heating. There were fire places, detached sheds, or pets observed in the home. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant was advised that any poisons must be locked with a key or combination lock. Based on the Facility Sketch submitted, areas off limits to children and parents are: The remaining two bedrooms, full bath, kitchen, dining room and front yard are off limits. The applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary. Page 1

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Timothy Fields	TELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019

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: FERNANDO FAMILY CHILD CARE	FACILITY NUMBER: 198020244
	VISIT DATE: 05/08/2019

NARRATIVE

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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.

Per applicant, there are no dual licenses at this address. Applicant’s email address was obtained during this inspection. The applicant was advised that email may be public information.

The following corrections need to be corrected prior to obtaining a small family child care license.
Corrections are due by 5/17/19

Applicant has to place a barrier around the wall heater.
Applicant Shamila Fernando has to complete the mandated reporter training.

A small family child care licensee will be granted upon receipt of proof of corrections for the above. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

Exit interview was conducted with, Applicant who agrees with the above.

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SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Timothy Fields	TELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019

LIC809 (FAS) - (06/04)

Page: 5 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: FERNANDO FAMILY CHILD CARE	FACILITY NUMBER: 198020244
	VISIT DATE: 05/08/2019

NARRATIVE

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OUTDOOR PLAY AREA
The children will use the back yard for outdoor play, which was observed to be fenced.
LPA obtained a Declaration (LIC855) from the applicant which states that children will be physically and visually supervised at all times.

Per applicant, there are no, firearms, weapons or bodies of water on the premises. There are toys available for children.

The value on the 2A10BC fire extinguisher indicates fully charged, as indicated on receipt submitted or service tag observed. Smoke and carbon monoxide detectors were tested and are operable.

The applicant states that they will provide food for children in care. If food is not provided and food is brought from the children’s homes; container shall be labeled with child’s name and properly stored or refrigerated.

The applicant has completed the required Health and Safety Training, Nutrition Training and Pediatric First Aid and CPR which expires 02/2021. 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 certification 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.
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SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Timothy Fields	TELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019

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: FERNANDO FAMILY CHILD CARE	FACILITY NUMBER: 198020244
	VISIT DATE: 05/08/2019

NARRATIVE

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· 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.
· 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 smoking, 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. Smoking on the premises is prohibited.

· 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.
· Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.
· Liability Insurance: Per applicant, she will be obtaining liability insures. LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

· UPDATE: 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.

· UPDATE: Health and Safety Code 1596.7995: 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

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SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Timothy Fields	TELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019

LIC809 (FAS) - (06/04)

Page: 3 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: FERNANDO FAMILY CHILD CARE	FACILITY NUMBER: 198020244
	VISIT DATE: 05/08/2019

NARRATIVE

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Infant Care: Applicant states that they will care for 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: Applicant states that infants will sleep in the dining room where she will be providing supervision. 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

Incidental Medical Services (IMS):
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).
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SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Timothy Fields	TELEPHONE: (323) 981-3431
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019

LIC809 (FAS) - (06/04)

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