304206561-10-16-2019-06-CC-SHAS-BGZUBG-20191016152618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304206561
Report Date: 10/16/2019
Date Signed: 10/16/2019 03:26:26 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:	WORTHING, KATHY		FACILITY NUMBER:	304206561
ADMINISTRATOR:	WORTHING, KATHY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 646-6339
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	14	CENSUS: 9	DATE:	10/16/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Kathy Worthing		TIME COMPLETED:	03:50 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	Licensed Program Analyst (LPA) Hawkins met with Kathy Worthing, Licensee and the purpose of the Annual/Random inspection of the facility was relayed to licensee. The home is a one level home with 3 bedrooms and 2 bathrooms. Licensee stated that OFF LIMITS areas include: all bedrooms, garage, living room, pool area. Home has an in ground pool with self-latching gate and 5 ft. fencing that meets regulations. Licensee must provide 100% visual supervision when the children are in an unfenced area. Licensee acknowledged that children may never enter these off-limit areas. Present during inspection was licensee's adult daughter/helper, mother, and teenage minor grandchild. A review of staff records indicates all facility staff or individuals who require caregiver background checks have received a criminal record clearance or exemption and a child abuse index clearance. Operating hours are 7 AM to 5:30 PM Monday to Friday. LPA observed 9 children (6 preschoolers, 3 infants) with 2 staff members. The facility was toured inside and outside. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. The items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children using child proof locks. Licensee stated there are no weapons in the home. Poisons/Hazardous items are stored out of children's reach. Food is prepared on site. Breakfast, lunch and snacks are provided by licensee. Food prep areas appeared clean and sanitary. Food is properly stored and the kitchen appears free from hazards. The toys, floors, and other equipment appeared clean. There is drinking water available to children both indoors and outdoors. The bathroom appear clean and sanitary. Children nap on blankets with pillows and bedding is washed by the facility. The facility has conducted an emergency drill within the past six months and the last one occurred on 9/4/2019. The facility has a working smoke detector, carbon monoxide detector, and fire extinguisher. The front yard where the children play is completely fenced. The play equipment appeared in safe condition. There appears to be sufficient cushioning underneath climbing structures and/or play equipment to absorb falls. Continued on page 2

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: WORTHING, KATHY	FACILITY NUMBER: 304206561
	VISIT DATE: 10/16/2019

NARRATIVE

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At least one staff member present possesses current CPR/First Aid certifications that is EMSA certified, which expires 04/2020. A sample of children’s files were reviewed for immunization's, Identification and Emergency Information, and Parents Rights. A sample of staff files were reviewed for a current CPR/First Aid, mandated reporter certificate, and immunizations.
LPA advised Licensee to tighten all screws on play structure to ensure children's safety.
Licensee stated she will provide an updated LIC 279 to identify persons living in the home. Licensee stated that her elderly mother has recently moved into the home and LPA verified that she has the criminal record clearance and have been associated to the home.

Incidental Medical Services (IMS) policy was discussed and at this time licensee does not provide any IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

Licensee was advised on how to receive notifications for quarterly updates and was provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov. Licensee was informed of where to access regulations and forms from CCLD website at: www.ccld.ca.gov
A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative.
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Licensee was provided with information on how to access the E-Learning Modules available at https://ccld.childcarevideos.org

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.
Exit interview was conducted. Report read out loud, reviewed and discussed. Notice of Site Visit was posted. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. Failure to post will result in Civil Penalties of $100.00.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019

LIC809 (FAS) - (06/04)

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