198020463-11-18-2019-33-CC-JCHZ-BJ2R6L-20191118114455

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020463
Report Date: 11/18/2019
Date Signed: 11/18/2019 11:45:02 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	MATA & HERNANDEZ FAMILY CHILD CARE		FACILITY NUMBER:	198020463
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	11/18/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Merlyn Mata, Applicant		TIME COMPLETED:	12:00 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	A PRELICENSING INSPECTION CONDUCTED IN SPANISH Licensing Program Analyst (LPA) Janeth Chavez conducted an announced pre-licensing inspection today. LPA met with Merlyn Mata whom guided LPA on a tour of the facility indoors and outdoors. This application is a change of location, the applicants are licensed at 447 S. Berendo St, Los Angeles, CA 90020 with license #198019111. This is a fourplex and the applicants live on the first floor. Family members residing in the home are 2 adults and 1 minor child. The applicants are Merlyn M. Mata & Leonel J. Hernandez. Per applicant operating hours will be Monday – Friday from 6:00am- 8:00pm. Applicant states they want to care for children birth to 12 years old. All areas identified on the facility sketch were inspected. This is a one-story home which consists of 2 bedrooms, 1 ½ Full Restrooms, kitchen, living room, dining room, laundry room, 2 closets, parking garage & front yard (fenced). The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. The home has air conditioning throughout the house. Areas off limits include: 2 bedrooms, full restroom, laundry room, kitchen, 2 closets, & parking garage. Areas used by children include: Living & Dining room (main daycare area), ½ Restroom adjacent to the dining room, and front yard (fenced). These areas are accessible during day care hours. LPA observed a wall heater in the dining room that is barricaded with a metal safety gate. As per applicant this wall heater will not be used during daycare hours. LPA observed two metal safety gates in the kitchen to prevent access to the kitchen and hallway that leads to the bedrooms, closets, laundry room and parking garage. Applicants were advised to keep all off-limit areas inaccessible to day care children at all times. LPA inspected the children’s bathroom and is free of hazards and included a changing table. The applicant stated that the children will be using the front yard as the main play area. The front LPA did not observe any hazardous items in the front yard. The applicant stated that the children will nap in the living room and eat in the dining room table. Report continued on attached LIC 809C page 1 of 3.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) -98-3417
LICENSING EVALUATOR NAME: Janeth Chavez	TELEPHONE: (323) 981-3376
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2019

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 3

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MATA & HERNANDEZ FAMILY CHILD CARE	FACILITY NUMBER: 198020463
	VISIT DATE: 11/18/2019

NARRATIVE

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As per applicant the parents will drop off and pick up children through the front entrance door. Applicant stated that transportation will be provided to the children in care. LPA reminded applicant to have liability insurance and proper car seats for the children in care. The cleaning compounds and detergents are latched under the kitchen sink. Applicant stated there are no poisons in the home. LPA did not observe any poisons in the home. There are no weapons or firearms in the facility. First Aid kit is available and is located in the children’s restroom. The home has electrical outlet covers throughout the home. There are age appropriate toys and napping equipment in the home. LPA did not observe bodies of water, pools, or jacuzzis. LPA did not observe stairs, pets, fire arms or fireplaces in the home.

The required fire extinguisher (2A10BC) is full and was purchased on (11/2019). Smoke detector (dining room) and Carbon Monoxide (living room) are in operable condition. Mrs. Merlyn M. Mata & Leonel J. Hernandez Pediatric CPR/1^st Aid certificates expire on 06/2020. The Preventative Health and Safety was training on 05/05/2016. Applicants have completed with AB 1207 Mandated Reporter training on 04/01/2018. Applicants have met SB792 requirements.

Forms to be posted:
LIC6101A Emergency Disaster Plan,
PUB394 Notification of Parents Rights Poster,
Facility License
Facility Records: LIC 624B Unusual Incident/Injury Report, LIC 9040 Child Care Facility Roster, LIC9052 Employee Rights, LIC9108 Statement Acknowledging Requirement to Report Child Abuse.
Staff Forms/Records - any assistant present must have the following on file: Proof of TB clearance (within one year), Notice of Employee Rights (LIC 9052), Criminal Record Statement (LIC 508), Statement Acknowledging Requirements to Report Suspected Child Abuse (LIC 9108).
Children’s records requirements: LIC 700 Identification and Emergency Information, LIC 627 Consent for Emergency Medical Treatment, LIC 282 Affidavit Regarding Liability Insurance, LIC 9150 Parent Notification Additional Children In Care, Immunization record, PUB 72- Family Child Care Consumer Guide, LIC 995A Notification of Parent’s Rights.

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.

Report continued on attached LIC 809C page 2 of 3.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) -98-3417
LICENSING EVALUATOR NAME: Janeth Chavez	TELEPHONE: (323) 981-3376
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MATA & HERNANDEZ FAMILY CHILD CARE	FACILITY NUMBER: 198020463
	VISIT DATE: 11/18/2019

NARRATIVE

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During this visit, the LPA Chavez reviewed and issued Forms/Records to Keep in Your Family Child Care Home (LIC 311D) to the applicant. LPA Chavez reviewed Sudden Infant Death Syndrome (SIDS), Shaken Baby Syndrome, and safe sleep practices with licensee. *Infants should always sleep on their backs, mouths facing up, light bedding.

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. 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. All adults working or living in the home must have their criminal record clearances on file PRIOR to working or living in the home. If finger print cleared, their clearances must be associated to facility PRIOR to working or living in the home. Failure to comply will result in an immediate Civil Penalty being assessed.
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, TB clearance, 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.
The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and 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.
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. Mandated reporter requirements were reviewed and explained
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, 24/7.
Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
No smoking, No baby bouncers, 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.
All adults living and working in the home shall be made of aware of the Departments right to inspection authority
LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing Website at: www.ccld.ca.gov. A final review of the application will be conducted by the Department. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. Exit interview was conducted with Merlyn M. Mata, applicant, who is in agreement with the above. A copy of this report and all other Licensing reports must be made available to the public for 3 years. End of Report 3 of 3

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) -98-3417
LICENSING EVALUATOR NAME: Janeth Chavez	TELEPHONE: (323) 981-3376
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3