198400129-10-22-2019-54-CC-RNAO-BH7SZ9-20191022141847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400129
Report Date: 10/22/2019
Date Signed: 10/22/2019 02:18:57 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:	SANDOVAL FAMILY CHILD CARE		FACILITY NUMBER:	198400129
ADMINISTRATOR:	SUSANNA SANDOVAL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(424) 215-6263
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	14	CENSUS: 0	DATE:	10/22/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Susanna Sandoval		TIME COMPLETED:	02:38 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) Raul Navarro conducted an announced pre-licensing visit today. Licensee is applying for a change of location. LPA met with Susanna Sandoval who guided the analyst on a tour of the facility. Family members residing in the home are 2 adults and 2 children, and two pet dogs. Per Applicant operating hours will be Monday through Friday from 6:00am to 6:00pm. Applicant states they want to care for children from birth to 15 years of age. All areas identified on the facility sketch were inspected. This is a one story home which consists of three bedrooms, three restrooms, kitchen, dining room, family room, front and backyard (fenced), and garage. 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. LPA observed outdoor play area (front and backyard) to be safe. Both the front yard and backyard are adequately fenced There is swimming pool on the premises. There are no windows or doors that provide direct access to the pool. The pool is made inaccessible with an iron fence. Fence is in good repair and is designed and installed so children could not remove any portion of it. Fence is at least five feet high and it is constructed so that it does not obscure the pool from view. Fence is not easily climbable by children. The only access to the pool is by a gate. The gate is kept closed with a pad lock. The gate swings away from the pool and is self latching. The openings between the railings does not exceed four inches. The bottom of the fence is not more than four inches from the ground. Fence is thick enough that it cannot easily be broken, removed or stretched by children. Report continues- Page 1 of 4

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul Navarro	TELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2019

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 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: SANDOVAL FAMILY CHILD CARE	FACILITY NUMBER: 198400129
	VISIT DATE: 10/22/2019

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
26
27
28
29
30
31
32

·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 was 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 baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines or 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.

During this visit, the LPA reviewed and issued Forms/Records to Keep in Your Family Child Care Home (LIC 311D) to the applicant. LPA reviewed Sudden Infant Death Syndrome (SIDS), Shaken Baby Syndrome, and safe sleep practices with Licensee.
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

Report continues- Page 3 of 4

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul Navarro	TELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2019

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: SANDOVAL FAMILY CHILD CARE	FACILITY NUMBER: 198400129
	VISIT DATE: 10/22/2019

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
26
27
28
29
30
31
32

Per applicant, there are no dual licenses at this address.

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

After a tour and review of this home the facility was in accordance with the California Code of Regulations Title 22 to protect the Health & Safety of child that will be in care.

After further review by the department, Applicant will be notified if/when License is granted.

Once licensed, the Applicant is required to adhere to the terms and limitation as stated on the license.
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 Applicant Susanna Sandoval 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.

Report ends- Page 4 of 4

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul Navarro	TELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2019

LIC809 (FAS) - (06/04)

Page: 4 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: SANDOVAL FAMILY CHILD CARE	FACILITY NUMBER: 198400129
	VISIT DATE: 10/22/2019

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
26
27
28
29
30
31
32

There are age appropriate toys and napping equipment in the facility. Areas off limits include: All three bedrooms, two bathrooms, kitchen, pool, and garage. Areas used by children include: living room, one bathroom, dining room, front yard, and backyard.

Knives are inaccessible to children. The required fire extinguisher (2A10BC) is in operable condition, last serviced 06/2019. Smoke detectors and carbon monoxide detectors are in operable condition. Per applicant there are no weapons, firearms in the facility at this time. First Aid kit is available in the kitchen.

Licensee has CPR/First Aid Certification received 02/2021 and also have Certification on Preventative Health and Safety training with nutrition included. Licensees also have current Mandated Reporter Training certification. Proof of immunization against influenza, pertussis, and measles for the Licensee and Assistant was readily available during today's inspection.

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.

·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 2-A10BC 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.

Report continues- Page 2 of 4

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul Navarro	TELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2019

LIC809 (FAS) - (06/04)

Page: 2 of 4