198400221-7-2-2020-54-CC-MRIA-BR5VHR-20200702162736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400221
Report Date: 06/26/2020
Date Signed: 07/02/2020 04:28:02 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:	LUCKEY FAMILY CHILD CARE		FACILITY NUMBER:	198400221
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	06/26/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Kelly Luckey, Applicant		TIME COMPLETED:	03:00 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	On June 26, 2020 at 1:30 PM, Licensing Program Analyst (LPA) Mayra Rivera conducted an announced via teleconference pre-licensing inspection. This pre-licensing inspection conducted by LPA Rivera, due to COVID 19 and precautionary measures the inspection was conducted via teleconference using FaceTime. The teleconference was conducted with applicant Kelly Luckey who guided LPA Rivera on a tour of the facility. Family members residing in the home is the applicant one adult child Tiera J. Ross. The applicant is requesting for a small family childcare home license. Operating hours will be Monday to Sunday, 12:00 AM to 11:00 PM. Per the applicant, operating hours will be changed to Monday to Friday, 6:00 AM to 6:00 PM and will complete an LIC 279 Application for Family Childcare to update operational days and hours. The applicant is applying to care for children ages 0 to 12. All areas identified on the facility sketch were inspected. This facility is a two story home that consists of three (3) bedrooms, one and half (11/2) bathrooms, kitchen, living room, den, front yard (gated), backyard (fenced) and garage. Areas that are accessible to children include: den (day care area), living room, kitchen, dining room, half restroom (working toilet, paper towels, hand soap and running water available), and backyard. Per applicant, children will utilize the backyard (fenced) for outdoor activity. Per applicant, parents will be utilizing the front door living room area for pick up and drop off. Areas off limits to children include: stairs, upstairs 3 bedrooms, 1 bathroom, closet/closet (washer and dryer) and garage. Off limits areas are locked and a safety gate for stairs has been installed. The applicant was advised that areas that are off limits must be made inaccessible during operating hours.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

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: LUCKEY FAMILY CHILD CARE	FACILITY NUMBER: 198400221
	VISIT DATE: 06/26/2020

NARRATIVE

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Areas that will be used by the children were inspected for safety, comfort, cleanliness, telephone service, ventilation and heating (central). Cleaning compounds underneath kitchen sink have been removed and placed above inside kitchen cabinet. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible. Child proof locks are put in place to make cabinets and drawers inaccessible. A safety gate for stairs is installed to prevent children going up stairs. The applicant states that there are no poisons in the home. The applicant was advised that if any poisons are purchased, it is required to be locked with a key or combination lock. Applicant was advised that if food is brought from the children’s home, all containers must be labeled with the child’s name and properly stored or refrigerated.

Per applicant, there are no pets, firearms, weapons or bodies of water on the premises. LPA Rivera did not observe age appropriate toys and napping equipment for the children. Applicant stated once she starts providing care, materials needed for children will be provided. The home has electrical outlet covers throughout the indoor facility and outdoor facility missing cover outlets. Applicant corrected the outdoor outlets by placing clear covers. Fire extinguisher is located in the kitchen and the valve on the required 2A10BC fire extinguisher indicates fully charged (purchased May 2,^, 2020). Smoke and carbon monoxide detectors were tested and are operable. A First Aid kit (purchased May 2, 2020) is available and is in the kitchen area.

The applicant has proof of pediatric First Aid/CPR certification (expires 07/07/2020). The applicant has proof of immunization against influenza, pertussis, and measles. The applicant completed the preventative health and safety training on 4/25/2020 and mandated reporter (AB 1207) training on 4/17/2020. The applicant was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com.

LPA Rivera issued Forms/Records to Keep in Your Family Child Care Home (LIC 311D) to the applicant. LPA Rivera provided material on the California Car Seat Law Changes (effective January 1, 2017), Effects of Lead Exposure, Shaken Baby Syndrome, Sudden Infant Death Syndrome (SIDS) and safe sleep practices.

Information to be posted in your home:
Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parents’ Rights Poster (PUB 394), and Facility License (LIC 203).

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

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: LUCKEY FAMILY CHILD CARE	FACILITY NUMBER: 198400221
	VISIT DATE: 06/26/2020

NARRATIVE

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Children’s Forms/Records to keep in your home:
Parent Notification, Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Consent for Medical Treatment (LIC 627), Consent/Verification for Nebulizer Care (LIC 9166), Identification and Emergency Information (LIC 700), Notification of Parents’ Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), California School Immunization Record (blue card) (PM 286), and Acknowledgment of Receipt of Licensing Reports (LIC 9224), if applicable.

Facility Forms/Records to keep in your home:
1. Personnel Records as required in Title 22, Division 12, Chapter 3, Section 102416.1, including but not limited to, proof of current pediatric first aid, CPR, preventative health practices certificate, mandated reporter training certificate and criminal record information.
2. Unusual Incident/Injury Report (LIC 624B
3. Child Care Facility Roster (LIC 9040)
4. Notice of Employee Rights (LIC 9052)
5. Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108)
6. Property Owner/Landlord Consent Form (LIC 9149)
7. Property Owner/Landlord Notification Form (LIC 9151).
8. A copy of your deed or lease/rental agreement.

The following was also discussed with the applicant:
1. Individuals who are 18 years of age or older and living in the home must obtain a criminal record clearance. Individuals within one month of their 18^th birthday must be fingerprinted immediately. Failure to obtain 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.
2. 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 and Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.
3. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

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: LUCKEY FAMILY CHILD CARE	FACILITY NUMBER: 198400221
	VISIT DATE: 06/26/2020

NARRATIVE

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4. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated.
5. 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.
6. 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.
7. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B). Mandated reporter requirements were reviewed and explained.
8. Fire and safety drills must be performed every six (6) months and documented for review by the Department.
9. Smoking is prohibited in the family childcare home.
10. Children and staff records must be maintained and updated as needed and be available for review by the Department.
11. Dog(s) and/or pets are recommended to be isolated from children in care.
12. No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into this category is not permitted in the facility.

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 Americans with Disabilities Act (ADA) was provided: U.S. 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.

LPA Rivera advised the applicant on how to access forms, regulations, quarterly updates, and Provider Information Notices (PIN) on the Department website: www.ccld.ca.gov.

At the time of the inspection, the applicant provided pictures of the following corrections: cleaning compounds removed and placed above inside kitchen cabinet inaccessible and outdoor outlets covered with clear covers.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

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: LUCKEY FAMILY CHILD CARE	FACILITY NUMBER: 198400221
	VISIT DATE: 06/26/2020

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A final review of the application will be completed prior to licensure. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license.

Exit interview was conducted with applicant Kelly Luckey, via teleconference. This report along with a copy of California Car Seat Law, Effects of Lead Exposure, Shaken Baby Syndrome, Sudden Infant Death Syndrome (SIDS), Safe Sleep Practices and the Appeal Rights will be sent to the Licensee via email(kelly.luckey@yahoo.com) with a read receipt to confirm receipt of the report, California Car Seat Law, Effects of Lead Exposure, Shaken Baby Syndrome, Sudden Infant Death Syndrome (SIDS), Safe Sleep Practices and the Appeal Rights.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

LIC809 (FAS) - (06/04)

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