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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313174
Report Date: 10/09/2019
Date Signed: 10/09/2019 11:36:04 AM

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:SMITH, TAMARAFACILITY NUMBER:
304313174
ADMINISTRATOR:SMITH, TAMARAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 619-2365
CITY:IRVINESTATE: CAZIP CODE:
92602
CAPACITY:14CENSUS: 12DATE:
10/09/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tamara SmithTIME COMPLETED:
12:00 PM
NARRATIVE
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An inspection was conducted at the facility by LPA, Dean Valencia. 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.

During today’s inspection the home and grounds were toured and the licensee was operating within the licensed capacity. There were 12 children in care at the time of the inspection, and two adults assisting with care. It was observed that the facility is operating out of compliance of ratio, there were 5 infants in care. A printout of ratio was provided and discussed. Operating hours are 7:30am to 5:30pm, Mon–Fri. The floor plan was verified. Off limits areas are made inaccessible by means of baby gate. The staircase is off limits to children. The licensee's pediatric CPR/First Aid certification is current, which expires 12/2019. 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, and is documenting these drills. 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, and is free from hazards. There are no bodies of water on the premises. Children's records were reviewed, and are missing some documentation. 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)
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2019
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 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: SMITH, TAMARA
FACILITY NUMBER: 304313174
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2019
Section Cited

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For a Large Family Child Care Home,..., shall be either Twelve children, no more than four of whom may be infants.

During a physical plant inspection and a review of the children's records, it was observed that there were 5 infants in care. This is an immediate threat to the children's
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health and safety.
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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2019
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: SMITH, TAMARA
FACILITY NUMBER: 304313174
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2019
Section Cited

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The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

Based on a review of the 12 children's records it was observed that 1 of the
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records of immunizations was not available to review. This is a potential threat to the children's health and safety.
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Type B
10/23/2019
Section Cited

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An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, medical care...

Based on a record review of the children's
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records, it was observed that 3 of the 12 records did not hane the Identification and Emergency Information form available to review. This is a potential threat to the children's health and safety.
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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2019
LIC809 (FAS) - (06/04)
Page: 4 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: SMITH, TAMARA
FACILITY NUMBER: 304313174
VISIT DATE: 10/09/2019
NARRATIVE
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Proof of immunization against pertussis, influenza (or written declination), and measles for licensee(s)/assistants/volunteers were reviewed and within compliance of SB 792.
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. LPA discussed safe sleep and new safe sleep concepts with the provider. 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. This training was discussed with provider, and certification of this training was reviewed. The provider was given a pamphlet on Lead Exposure and was discussed with provider.

Exit interview was conducted, and this report was reviewed and discussed. Notice of Site Visit was posted during the visit. The licensee was informed that the Notice of Site Visit must be posted for 30 consecutive days from today's date. Failure to post and remain posted will result in civil penalties of $100 per day. The licensee was provided a copy of their appeal/licensee rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional manager, office address is on page 1 of this report. The licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. and accessibility/information about the website was discussed with the provider. This report is to be on file and accessible for public review at the facility, for the next 3 years.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see attached LIC 809D.
Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign form LIC9224 to be kept in each child's file.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4