<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304311808
Report Date: 05/31/2019
Date Signed: 06/05/2019 04:28:33 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:SCOTT, NICOLEFACILITY NUMBER:
304311808
ADMINISTRATOR:SCOTT, NICOLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 585-3883
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:14CENSUS: 8DATE:
05/31/2019
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Nicole ScottTIME COMPLETED:
12:10 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
Licensing Program Analyst (LPA) S. Hawkins made an unannounced visit to the facility to conduct an inspection to ensure the facility is complying with licensing regulations. Present at the start of this licensing report was licensee, assistant Angelica Perez, licensee mother Cyndee Montgomery and one minor child. Upon arrival there were six children in care (2 infants, 4 preschoolers), two additional children (1 infant, 1 preschooler) arrived during the visit making the total census of 8. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently 2 adults living in the home. Licensee informed LPA that there was a change in the household and one adult has moved out and the adult assistant has moved in.

During today’s inspection the home and grounds were toured and the licensee was operating within the licensed capacity. An assistant was present assisting with care. Operating hours are 6:45am to 5:45pm, Mon–Fri. Off limits areas are made inaccessible by means of baby gates and high latches. The licensee's pediatric CPR/First Aid certification is current, which expires 10/20. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Poisonous items are not stored on site, and none were observed during today's inspection. There is a working carbon monoxide detector, smoke detector, and fire extinguisher in the home. The licensee has a current roster of children in care. The facility has conducted an emergency drill within the past six months. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's visit. The children use the backyard as the outdoor play area, and it is completely fenced. Licensee stated that the backyard is temporarily off limits due to construction of the wooden fence. There are no bodies of water on the premises. Staff files were reviewed for immunization's, tuberculosis, and mandated reporter training. Children's records were reviewed for immunization's, parents rights, and emergency contact form. All children's and staff files were in substantial compliance.

Continued on page 2
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019
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 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: SCOTT, NICOLE
FACILITY NUMBER: 304311808
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2019
Section Cited
CCR
102416.2(a)(2)
1
2
3
4
5
6
7
Reporting Requirements Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday. This requirement was not met as evidenced by Licensees failed to notify CCL of persons(assistant) moving in the home. This poses a potential risk to the safety of children in care.
1
2
3
4
5
6
7
Licensee will provide an updated LIC 200 application to include the updates. Licensee will mail form to office by the due date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019
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: SCOTT, NICOLE
FACILITY NUMBER: 304311808
VISIT DATE: 05/31/2019
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
26
27
28
29
30
31
32
Continued page 2
This facility does not provide IMS services at this time. 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 .
(continued on LIC809C)


After a tour of the home and review of children and staff's records, the following deficiency was observed :The licensee has another person living in the home and did not notify the department which poses a safety risk to the children in care.
The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 Section 102416(a)(2) were observed, discussed and cited at the time of the visit. (See LIC 809-D for specific deficiencies)
An exit Interview was conducted. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional Manager, address is above on the report.

The licensee was advised on how to receive notifications about quarterly updates, and provided with the Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov


A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Safe Sleep Regulation Concepts (4/2018) was provided for the Licensee.
Beginning January 1, 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 NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. The NOTICE must remain posted for 30 days. FAILURE TO POST ANY OF THE REQUIRED SITE VISIT REPORTS FOR 30 CONSECUTIVE DAYS WILL RESULT IN AN IMMEDIATE CIVIL PENALTY OF $100.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3