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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300608498
Report Date: 01/16/2020
Date Signed: 01/16/2020 03:56:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:CLEMENS, GLORIA & LARRYFACILITY NUMBER:
300608498
ADMINISTRATOR:CLEMENS, GLORIA & LARRYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 956-7236
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:14CENSUS: 8DATE:
01/16/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Assistant - Sandra OdogwuTIME COMPLETED:
04:15 PM
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An unannounced annual inspection was conducted at the facility by Licensing Program Analyst’s (LPA’s) Odom and Taylor. LPA’s met with Assistants and toured the entire facility. LPA’s observed 2 infant, and 6 preschool age children in the child care room with Assistants Sandra Odogwu and Arlene Herrera. The facility was within licensed capacity and the required ratio. Assistant stated there are presently 3 adults living in the home. Licensee, Licensee husband, adult son. Child care operating hours are Monday through Friday, 7:00a.m. to 5:30p.m. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During today’s inspection each child was observed to have safe, healthful, and comfortable accommodations, furnishings, and equipment. The floor plan was verified; 2 story home, 4 bedrooms, and 2 restrooms. Assistant stated all three bedrooms, master bathroom, garage, living room, and kitchen are off-limits. Off limits areas are made inaccessible by means of baby gates, door knobs and door locks. The accessible child care areas are family back room, bathroom in the family room and one bedroom in the first floor by the kitchen. The children use the back yard as the outdoor play area, and it is completely fenced. The outdoor play area is free from hazards. The front yard is off limits. Home has a fireplace and wall heater is fenced. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children in garage and locked. Poisonous items are not stored on site, and none were observed during today's inspection. The facility provides safe toys, equipment, and materials. There is a working combined carbon monoxide detector and smoke detector, and fire extinguisher (2A10BC) in the home that meet statutory and State Fire Marshall standards. The facility has conducted an emergency drill within the past six months. The assistant stated there are no firearms or other dangerous weapons in the home. The facility does not have body of water at the facility.

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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CLEMENS, GLORIA & LARRY
FACILITY NUMBER: 300608498
VISIT DATE: 01/16/2020
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The LPA advised the assistant to contact licensing department for any changes to hours and days of planned operation, and for any changes to facility, including on/off limit areas and change in phone number. The licensee has a lain-line home phone that is used for child care. The licensee was reminded that if a cell phone is used as the primary child care phone, it must remain on the premises always during hours of operation.

The licensee does have a current children roster (LIC9040) at the facility. Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC700), Notification of Parents’ Rights receipts (LIC995), California School Immunization Records (blue card). LPA observed that 1 out of the 8 Children’s files did not have the California School Immunization Records (blue card), LPA advised Licensee will need to obtain copies of the child’s immunization records immediately. The assistant’s Pediatric CPR/First Aid certification expire on 09/2021. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for assistants were reviewed and within compliance. Assistants provided a written declaration to decline against taking the influenza.

Beginning March 31, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years, per A.B. 1207. The assistants have Mandated Reporter training completed on 09/2019.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020
LIC809 (FAS) - (06/04)
Page: 2 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CLEMENS, GLORIA & LARRY
FACILITY NUMBER: 300608498
VISIT DATE: 01/16/2020
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The licensee understands she must be present in the facility and must ensure children in care are always supervised and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization, Pediatric CPR/First Aid, and mandated reporter training.

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.

A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:

English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP:https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with licensee the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.
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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CLEMENS, GLORIA & LARRY
FACILITY NUMBER: 300608498
VISIT DATE: 01/16/2020
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The following were discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to presence in the facility. Individuals within one month of their 18th birthday must be fingerprinted immediately. No smoking, no infant walkers, baby bouncers, Johnny Jumpers, exersaucer or any other similar items that fall into that category are allowed in the facility. Disaster drills, posting requirements, children record, mandated child abuse and injury/ death reporting, and criminal records clearances/exemption transfer requests, SIDS and Never Shake a Baby. LPA reviewed how to report an unusual incident.

In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Inspection, report review and exit interview was conducted with Assistant in English. Notice of Site Visit was posted during the visit. Licensee was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Appeal rights provided and explained. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4