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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400221
Report Date: 07/06/2021
Date Signed: 07/06/2021 04:51:40 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 CAREFACILITY NUMBER:
198400221
ADMINISTRATOR:KELLY LUCKEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
3233462788
CITY:LOS ANGELESSTATE: CAZIP CODE:
90011
CAPACITY:14CENSUS: 8DATE:
07/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Kelly Luckey, LicenseeTIME COMPLETED:
05:00 PM
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Prior to entrance to the facility, LPA Mayra Rivera conducted a Covid 19 assessment and based on the licensee responses to the facility assessment questions, LPA Rivera determined safe to proceed. On Tuesday, July 6, 2021 at 1:19 PM, Licensing Program Analyst (LPA) Mayra Rivera conducted an annual inspection and met with Licensee Kelly Luckey who guided LPA Rivera on a tour of the facility.

During the inspection, 8 children ( one 17 months, 6 preschool and one school age) and assistant Deetta Champ were present. LPA Rivera observed 8 children napping. Family members residing in the home was been discussed with licensee and are cleared. Operating hours are Monday to Friday, 6:00 AM to 6:00 PM and care for children ages 0 to 12 years.

This facility is a two story home that consists of three (3) bedrooms, one and half (11/2) bathroom, kitchen, living room, den, front yard (gated), backyard (fenced) and garage. Areas that are accessible to children and identified on the facility sketch were inspected by LPA Rivera; den, living room, kitchen, dining room, half restroom and backyard

Areas off limits to children include: stairs, upstairs 3 bedrooms, 1 bathroom, closet (washer and dryer), shed and garage. At 1:25 PM, LPA observed a safety gate installed on the bottom of the stairs as a barrier and the gate door closed. LPA observed the door that leads to the garage closed and locked with a dead bolt lock.

At 1:33 PM LPA Rivera entered the daycare room area to inspect for safety, comfort, cleanliness, ventilation and working phone (land line). For ventilation, LPA Rivera observed thermostat for heater and the vents located on high ceiling wall, and windows. LPA did not see a fireplace during the inspection. LPA observed a cubby storage with children personal belongings, two other cubbies with children materials such as art supplies, puzzles, and manipulative. LPA observed the furniture and children materials to be in good condition and age appropriate.

SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: LUCKEY FAMILY CHILD CARE
FACILITY NUMBER: 198400221
VISIT DATE: 07/06/2021
NARRATIVE
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 At 1:39 PM, LPA Rivera entered the restroom and observed the toilet, running water, hand soap and paper towels. LPA observed the bottom cabinets closed and with a child proof lock in place making it inaccessible to children to open the cabinet doors. LPA observed the restroom to be in good condition.

At 1:42 PM LPA observed cleaning compounds items stored inside the cabinets above the stove cabinet and the detergents inside the washer/dryer closet above the washer making it inaccessible to children. LPA observed the kitchen cabinets doors closed and with a safety latches in place to make it inaccessible to children to open the drawers. Licensee understands that any poisons or firearms must be locked with a key or combination lock. For drinking water, LPA observed water bottles and disposable cups.

LPA Rivera asked if there are any pets, poisons, firearms, weapons or bodies of water. Licensee stated she has no personal pets and is currently caring/sitting a tea cup yorkie dog. License stated "no", firearms, or weapons. LPA did not observe firearms or weapons. Licensee was advised that if any poisons (ex; drano, rat poison or items with skull hazard symbol), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition must be stored separately.



At 1:45 PM LPA Rivera observed the required 2A10BC fire extinguisher located in the living room and the valve on the green area indicating fully charged and purchased receipt dated 5/24/21. At 2:40 PM LPA asked licensee to press on the smoke detector located in the hallway and the carbon monoxide alarm that is located in the living room. LPA heard the sounds of the smoke and carbon monoxide alarms. The alarms are operating.

At 1:50 PM LPA inspected the outdoor area used by children in care for safety, comfort and cleanliness, LPA observed backyard to be fenced all around. The side gates closed with self latch. LPA observed an EZ Up anchored to the grass and provides an area for shade. LPA observed a toddler playground, balls, trick bikes and hula hoops. LPA observed play equipment to be in good condition and age appropriate. LPA observed a small kiddie pool with some water. LPA advised licensee to dump out the water.

LPA observed licensee pediatric First Aid/CPR certification (expires 06/30/2022) and has proof of immunization against pertussis, measles and LPA received influenza declination dated May 19, 2021. Licensee has completed the preventative health and safety training on 4/25/2020 and mandated reporter (AB 1207) training on 4/17/2020. Licensee was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com.

SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: LUCKEY FAMILY CHILD CARE
FACILITY NUMBER: 198400221
VISIT DATE: 07/06/2021
NARRATIVE
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At 2 05 PM LPA observed on the bulletin wall the children's facility roaster, LIC 610 Emergency Disaster plan, Parents Rights, License, LIC 9148 Earthquake preparedness checklist, and facility sketch..

The following was discussed: .

INFANT CARE: LPA Rivera reviewed and discussed Safe Sleeping Practices information with licensee and a plan for supervising sleeping infants. LPA advised the licensee to sleep infants in an area where infants can be directly supervised. Place infants on their backs to sleep, on a firm mattress with fitted sheet that fits snugly in crib or play yard. LPA also advised against sleeping infants in a separate room with no direct supervision and no pillows, crib bumpers, swaddling, head covered, and pacifiers must not have anything attached. Safe sleep brochure was provided.

LPA Rivera also reviewed Sudden Infant Death Syndrome (SIDS), Never Shake A Baby, and Lead Exposure information with licensee.. LPAs also explained to licensee that car seat, stroller are only and only for transportation, high chair is only and only for feeding and stated items cannot be misused. No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into this category are not permitted in a family child care facility.



Medication: 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

LPAs advised the licensee how to access forms, regulations and quarterly updates , and Providers Information Notices (PIN) on line at: www.ccld.ca.gov



LPA issued the Confidential Names List (LIC 811) to the licensee during the inspection. The Confidential Names List documents the children’s and staff files that were reviewed during this inspection. LPA did not observe licensing form LIC 9150 Parent notification additional children in care, LIC 700 Identification and emergency information, and LIC 995A receipt of Notification of parents rights in the children files.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: LUCKEY FAMILY CHILD CARE
FACILITY NUMBER: 198400221
VISIT DATE: 07/06/2021
NARRATIVE
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Assistant Deetta Champ is missing influenza or declination employee rights form and Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108)

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.



Licensee has been given an advisory notice to empty the water from the kiddie pool, and to obtain assistant influenza or influenza declination, employee rights and Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108).

The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D. Deficiencies that are being cited need to be cleared to protect the children’s health & safety. Exit interview was conducted and plans of correction were reviewed and developed with Licensee, Kelly Luckey. Appeal rights explained & provided. A copy of this report and appeal rights were discussed and left with licensee, Kelly Luckey whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: LUCKEY FAMILY CHILD CARE
FACILITY NUMBER: 198400221
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/06/2021
Section Cited

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Child's Records

Children's records were reviewed and missing LIC 700 Identification and Emergency Information form and LIC 9150 Parent notification additional chidlren in care form. Based on LPAs record review C1, C2, and C3 did not have LIC 700 Identification and Emergency Information form
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 and LIC 9150 Parent notification additional chidlren in care from their file. This poses a potential health, safety, or personal rights risk to children in care.
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Type B
07/06/2021
Section Cited

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Admission Procedures and Parental and Authorized Representative Rights

Children's records were reviewed and missing copy of receipt LIC 995 Parent's Rights. Based on LPAs record review C1, C2, and C3 did not have LIC 995A copy receipt.
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This poses a potential health, safety, or personal rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2021
LIC809 (FAS) - (06/04)
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