198020935-12-22-2021-33-CC-RLOZ-C9XNUK-20211222094629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020935
Report Date: 12/21/2021
Date Signed: 12/22/2021 09:46:49 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:	CARLSON FAMILY CHILD CARE		FACILITY NUMBER:	198020935
ADMINISTRATOR:	CARLSON, NUBIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 715-5565
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY:	14	CENSUS: 0	DATE:	12/21/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nubia Carlson, Applicant		TIME COMPLETED:	12:30 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	An announced Pre- Licensing Inspection was conducted by Licensing Program Analyst (LPA) Roxana Lopez. A risk assessment was conducted upon entry- appropriate PPE was used. The purpose of today's visit is to inspect and evaluate facility for initial licensure, Applicant is applying for a Large Family Child Care Home. Present during this inspection was Applicant, her husband, mother in law and two children. Per applicant, family members residing in the home are 2 adults and 2 Children. Per applicant, operation hours will be Monday to Saturday, 6:00 AM to 6:00 PM. Applicant states that she will care for children 12 months- 10 years of age. During this inspection the following was observed: All areas identified on the facility sketch were inspected, including but not limited to, all off limit areas. This is a one-story home that consists of 3 bedrooms, 2 restrooms, kitchen, living room, dininng room, laundry room, front yard, backyard (fenced) and garage. Per applicant, the children will use 2 restrooms, living room, one bedroom/playroom, dining room, kitchen and backyard fence. Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service cell phone, ventilation and heating. 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 states that there are poisons on the premises which are locked in the off limits garage. Based on the Facility Sketch submitted, areas off limits to children and parents are: The front yard, two bedrooms and garage. ----------------------------------------------- Pg. 1 of 5 --------------------------------------------------------------------------

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Roxana Lopez	TELEPHONE: (323) 854-5073
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CARLSON FAMILY CHILD CARE	FACILITY NUMBER: 198020935
	VISIT DATE: 12/21/2021

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 observed an air conditioner unit, with openings wide enough for a child to place their fingers inside. Per applicant, she will add some type of barricade to make area inaccessible to children in care.

This facility plans to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

At 10:15 AM 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.
• Fire and safety drills must be performed every six months and documented for review by the Department.

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SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Roxana Lopez	TELEPHONE: (323) 854-5073
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 2 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CARLSON FAMILY CHILD CARE	FACILITY NUMBER: 198020935
	VISIT DATE: 12/21/2021

NARRATIVE

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All areas inaccessible for children were observed to have a lock and or a security gate making them inaccessible for children in care. The applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

LPA Lopez observed three fire extinguishers- one in the hallway, kitchen, and playroom. The valves on the 2A10BC fire extinguishers (in hallway) indicates fully charged and was purchased on 1/25/2020 as indicated in the receipt. LPA Lopez observed two fireplaces in the facility, one in the living room and the other one in the playroom. Both fireplaces were observed to barricaded and inaccessible for children in care. Smoke and carbon monoxide detectors were tested during the inspection and observed to be operable.

There are toys available for children. LPA observed sleeping arrangements in forms of cots and a playpen.

Infant Care: Applicant states that they will care for infants. LPA discussed the safe sleep regulations with Applicant Nubia 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 Applicant 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.

The applicant states that they will provide food for children in care and is planning to apply for the food program.

The applicant has completed the required Health and Safety Training, Nutrition Training and Pediatric First Aid and CPR. There are first aid supplies available.

Per applicant, there are weapons in the facility, weapons were observed to be locked in an off limits area in the facility. Per applicant there’s no bodies of water on the premises. LPA did not observed any bodies of water.

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SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Roxana Lopez	TELEPHONE: (323) 854-5073
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CARLSON FAMILY CHILD CARE	FACILITY NUMBER: 198020935
	VISIT DATE: 12/21/2021

NARRATIVE

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• 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.
• 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.
• 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

At 10:25 am LPA reviewed and issued the LIC 311D - Forms/Records to Keep in Your Family Child Care Home. All required forms listed were explained and were provided to the applicant during the visit.

LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

OTHER INFORMATION AND FORMS PROVIDED:
· Handouts provided for Never Shake a Baby, Sudden Infant Death Syndrome (SIDS) and Safe Sleeping practices
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SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Roxana Lopez	TELEPHONE: (323) 854-5073
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CARLSON FAMILY CHILD CARE	FACILITY NUMBER: 198020935
	VISIT DATE: 12/21/2021

NARRATIVE

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· Capacity Handout for a Small Family Child Care Home and Large Family Child Care Home was provided.
· Lead Exposure Flyer

LPA consulted with applicant regarding COVID-19 health and safety guidelines on this date, applicant was provided forms to post via email. Licensing staff observed COVID- 19 postings posted in the day care on this date.
During this inspection LPA discussed PIN 20-06 CCP, Social and Physical Distancing Guidance And Healthy Practices For Child Care Facilities In Response To The Global Coronavirus (COVID-19) Pandemic Written In Collaboration With The California Department Of Education. LPA reviewed with the applicant the Child Care Covid-19 Self-Assessment guide that the applicant filled out before this inspection.
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 applicant’s signature on this report acknowledges that they have signed the Application for a Family Child Care Home License (LIC 279) under the penalty of perjury that the statements on the application and any attachments are correct.

Applicant is seeking to provide care for 14 children 12 months- 10 years old. A fire clearance was granted on 12/7/2021. Based upon today’s inspection, the following correction needs to be completed by 12/23/2021,

- Cover on air conditioner unit- per applicant a barricade will be placed around the air conditioner to make area inaccessible for children.

The application will be submitted for final review to the department once the corrections have been received. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license.

The Notice of Site Visit (LIC 9213) – A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Applicant Nubia Carlson.

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SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Roxana Lopez	TELEPHONE: (323) 854-5073
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

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