304310878-9-9-2019-06-CC-GCOY-BFUS99-20190909134023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304310878
Report Date: 09/09/2019
Date Signed: 09/09/2019 01:40:32 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:	DAVIS-HENDERSON, ANNASTASIA		FACILITY NUMBER:	304310878
ADMINISTRATOR:	DAVIS-HENDERSON,ANNASTASIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 510-4663
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	14	CENSUS: 12	DATE:	09/09/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Annastasia Davis-Henderson		TIME COMPLETED:	01:50 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	Annual inspection conducted this date by Licensing Program Analyst (LPA) Connolly. Present was licensee, licensee's assistant Kelley Metoyer and 12 children in care 5 of whom infants. With 5 infants in care licensee is operating over the ratio of the large family child care home license. The publicly accessible license states: Maximum capacity when an assistant is present: 12 children no more than 4 infants. 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. The facility was toured inside and out. The following areas were checked: facility clean and in good repair, hazards inaccessible or locked, fire extinguisher, carbon monoxide detector and smoke detector operational, disaster drills practised, stairs barricaded, fire place screened, bodies of water inaccessible, guns locked, children immunization records maintained, Notification of Parents' Rights provided, and pediatric CPR First Aid cards current. The facility, clean and in good repair, is two story detached. Licensee has designated the following areas of the home for the care and supervision of children: living room/dining area redesigned as a play room, one downstairs bedroom for the napping of infants and hallway bathroom. A barrier at the bottom of the staircase leading to the second story of the home was in place at the time of the LPA arrival. The fire place was screened. Disaster drills are practised. The fire extinguisher, smoke detector and carbon monoxide detector are within regulation. Licensee's pediatric CPR and pediatric first aid training is current until 8/24/2021. The fenced backyard is designated as the outdoor play area for children in care. Outdoor play equipment located here appears age appropriate for ages served. Cushioning material is underneath and surrounding the outdoor play equipment. There are no bodies of water. Licensee said when children in care are playing in the designated outdoor play area 100% visual supervision is provided. Continue on page two

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine Connolly	TELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2019

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: DAVIS-HENDERSON, ANNASTASIA	FACILITY NUMBER: 304310878
	VISIT DATE: 09/09/2019

NARRATIVE

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page two
Licensee denies firearms on the premises. Children paperwork is complete.
During today’s inspection LPA discussed incidental medical services with the licensee. Licensee said there are no incidental medical services being provided at this time.

Licensee was reminded:
1.) Always place infants on their backs for sleeping.
2.) Use only a tight fitting sheet on the crib or play yard mattress.
3.) Do not hang any items form the crib or above the crib.
4.) Keep all items, including blankets, out of the crib or play yard.
5.) Pacifiers may be used as long as they do not have items attached to them.
6.) Infants should not be swaddled or have any items covering them while sleeping.

In the areas that were evaluated the facility was not in compliance and one violation of the California Code of Regulations, Title 22, Division 12 was observed, discussed and cited at the time of the inspection. Based on LPAs observations and children file review the following violation was observed and is being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 102416.5(a), on the attached LIC 809D.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days. If the facility receives a Type 'A' violation the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days. The licensee is to keep Acknowledgement Receipt (LIC9224) signed by parents in each child’s file.

Notice of Site Visit was posted. 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. The 'Notice of Site Visit' must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine Connolly	TELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: DAVIS-HENDERSON, ANNASTASIA	FACILITY NUMBER: 304310878
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/10/2019 Section Cited	1 2 3 4 5 6 7	102416.5(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This regulation is not met by LPA's file review which disclosed that 5 of the 12 children in care are infants. The large family child care home license allows for 12 children in care 4 of whom infants.
	8 9 10 11 12 13 14	Operating with too many infants in care poses an immediate risk to the health and safety of children in care.	8 9 10 11 12 13 14	LPA has provided email address.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine Connolly	TELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2019

LIC809 (FAS) - (06/04)

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