198400006-5-31-2019-54-CC-WBIS-BCPRHH-20190531130223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400006
Report Date: 05/31/2019
Date Signed: 05/31/2019 01:02:32 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:	GREEN FAMILY CHILD CARE		FACILITY NUMBER:	198400006
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	05/31/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:32 AM
MET WITH:	Jenae Green		TIME COMPLETED:	01:15 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) Warren Birks conducted an announced pre-licensing inspection today. This pre licensing is the result of the licensee transferring locations. LPA met with Licensee Jenae Green who guided analyst on a tour of the facility. There are two fingerprint cleared adults residing in the home (which includes the licensee) and a minor school age child. Operating hours will be Monday to Sunday 12:00am to 11:59pm. Applicant will care for children eight weeks to 12 years old. All areas identified on the facility sketch were inspected. This is a one story home which consists of three bedrooms, two full bathrooms, living room, kitchen, dining area, front yard, backyard and garage. There is no fireplace. The applicant uses the large back bedroom, back bathroom and backyard for daycare. 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. Per applicant, there are no dual licenses at this address. LPA observed age appropriate toys and napping equipment for infants. The outdoor play area is surrounded by a wooden gate and is safe and free of hazards at this time. The Licensee submitted a written statement that the backyard driveway will not be used for vehicles. Licensee was advised to provide 100% supervision for safety regarding the outdoor play and field trips. Note: The home is undergoing kitchen remodel construction however, the construction is in an off-limits area and inaccessible to children by locked doors. Parents and children have no access to any area accept the back bedroom activity area and backyard. This area has a bathroom. Children and parents enter through the side gate through the backyard double doors at this time. Areas off limits include: Licensee's bedroom, front bedroom, kitchen, living room, front bathroom and garage. The Smoke detector and carbon monoxide detector in the back room is in operable condition. Per applicant there are no weapons or firearms on the premises.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Warren Birks	TELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019

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: GREEN FAMILY CHILD CARE	FACILITY NUMBER: 198400006
	VISIT DATE: 05/31/2019

NARRATIVE

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First Aid kit is available and is in the closet Licensee's CPR/First Aid expires in 2020. LPA advised applicant to review Safe Sleep for your Baby (Infant Death Syndrome (SIDS), and safe sleep practices with licensee. *Infants should always sleep on their backs, mouths facing up, light bedding.*

The following was discussed:

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 9180).
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. Currently the applicant does not providing IMS at this time. All applicants immunization records are current.

·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.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Warren Birks	TELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019

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: GREEN FAMILY CHILD CARE	FACILITY NUMBER: 198400006
	VISIT DATE: 05/31/2019

NARRATIVE

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·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 or higher 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 permitted in the facility.
·All adults living and working in the home shall be made of aware of the Departments right to inspection authority.

Note: The Licensee's new transfer location is approved and active for a small family child care license effective 6/01/2019.

LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing Website at: www.ccld.ca.gov Exit interview was conducted with Licensee Green 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.

SUPERVISOR'S NAME: Brandi VanOosten	TELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Warren Birks	TELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019

LIC809 (FAS) - (06/04)

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