198400154-11-7-2019-54-CC-RJOS-BHPRJH-20191107120357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400154
Report Date: 11/07/2019
Date Signed: 11/07/2019 12:04:13 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:	KEITH & HOLLINS FAMILY CHILD CARE		FACILITY NUMBER:	198400154
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	11/07/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Bionka Keith_Licensee		TIME COMPLETED:	12:10 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) Reiko Jones-Modeste conducted a pre-licensing inspection. LPA met with applicants, Bionka Keith and Brandon Hollins Sr. who guided analyst on a tour of the facility. Two adults and five children currently reside in the home. All areas identified on the facility sketch were inspected. This is a one story home which consists of two bedrooms, one bathroom, kitchen, living room, backyard and front yard (fenced). The children will use the living room and one bedroom. These areas were inspected for safety, comfort, cleanliness, telephone service, ventilation and heating. There is a wall heater in the living room and bedroom which were inaccessible. Areas off limits to children and parents include: One bedroom, doors to these areas are locked with a key lock and inaccessible The applicant does understand that licensing staff may have access to off-limit areas during inspection visit if necessary. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children were inaccessible in the kitchen. LPA observed poisons inaccessible in the locked garage. Per applicant there are no weapons, firearms or bodies of water on the premises. There are no pets in the home. LPA observed appropriate toys clean and free of sharp edges. Emergency Disaster Plan, Disaster Drill log, Parents Rights, Car Seat Law and Safe Sleep Guidelines posted at the time of visit. The valve on the required 2A 10BC fire extinguisher indicates fully charged. Smoke and carbon monoxide detectors were tested, and operable. Applicants have completed the Health and Safety Training, including Nutrition requirement. Licensees Pediatric CPR and First Aid training were observed. Pediatric First Aid and CPR expires on July 2020.

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Reiko Jones	TELEPHONE: (323) 558-2739
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2019

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: KEITH & HOLLINS FAMILY CHILD CARE	FACILITY NUMBER: 198400154
	VISIT DATE: 11/07/2019

NARRATIVE

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Facility Forms/Records:
Proof of current Pediatric first aid and CPR must be available at all times; Unusual Incident/Injury Report (LIC 624B); Child Care Roster (LIC 9040); Property Owner/Landlord Consent Form (LIC 9149); A copy of your Control of Property should be readily available.

Information Required to be Posted in Your Family Child Care Home
Facility License; Notification of Parents’ Rights Poster (PUB 394); Emergency Disaster Plan (where readily available in case of an emergency; Earthquake Preparedness Checklist (LIC 9148) – attach to Emergency Disaster Plan; Once licensed – Notice of Site Visit must be posted for 30 days and any report documenting a Type A violation must be posted.

Assistant Requirements:
1)Proof of TB clearance (within one year); 2) Notice of Employee Rights (LIC 9052); 3) Criminal Record Statement (LIC 508); 4) Statement Acknowledging Requirements to Report Suspected Child Abuse (LIC 9108), 5) Mandated Child Abuse Reporter Training Certificate, 6) Required immunization's MMR, Influenza and Pertussis.

Applicant has been advised of the following:
· 101217 (g)(9)(A)(1) - Fire and earthquake drills must to be conducted and documented every six months. Documentation must be readily available
· Any assistant left alone with children must have proof of current pediatric first aid and CPR on file (AB 1368), required immunization's and the AB1207 Mandated Child Abuse Reporting training.

Control of property was submitted to the Department. Per applicant, there are no dual licenses at this address. LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

The applicant will be approved for a small family child care license upon a final file review.
Once licensed, the applicant is required to adhere to the terms and limitation as stated on the license.

Exit interview was conducted with, 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.

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Reiko Jones	TELEPHONE: (323) 558-2739
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2019

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: KEITH & HOLLINS FAMILY CHILD CARE	FACILITY NUMBER: 198400154
	VISIT DATE: 11/07/2019

NARRATIVE

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There are first aid supplies on the premises. Applicant's have completed the AB1207 Mandated Child Abuse Reporting training, certificates are on file.

The following was discussed: 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.

If an individual has already obtained a criminal record clearance with the Department, the criminal record clearance may be transferred. A Criminal Background Clearance Transfer Request form - LIC 9182, Criminal Record Statement LIC 508 and a copy of the individuals identification must be submitted to transfer any criminal record clearances. Prior to submitting this form, you must call our office to verify that the individual has an active criminal record clearance.

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.

The following was also discussed: CHILDREN’S FORMS/RECORDS, FACILITY FORMS/RECORDS and INFORMATION TO BE POSTED, Disaster drills, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal record transfer requirements, criminal record and child abuse clearances.

LPA reviewed and issued the LIC 311 - Forms/Records to Keep in Your Family Child Care Home. The following required forms were explained to the applicant during this visit.

Children’s Records Forms:
Parent Notification Additional Children in Care (LIC 9150); Consent For Emergency Medical Treatment (LIC 627); Consent/Verification for Nebulizer (LIC 9166); Identification and Emergency Information (LIC 700); Notification of Parents’ Rights (LIC 995A); Caregiver Background Check Process (LIC 995E); Family Child Care Awareness Information (LIC 9212); California School Immunization Record (PM 286); Acknowledgement of Receipt of Licensing Report (LIC 9224).

SUPERVISOR'S NAME: Trevino Cochran	TELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Reiko Jones	TELEPHONE: (323) 558-2739
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2019

LIC809 (FAS) - (06/04)

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