304313633-7-26-2019-06-CC-SHAS-BEFRNT-20190726131051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313633
Report Date: 07/26/2019
Date Signed: 07/26/2019 01:11:03 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:	ALGAMA, DONA		FACILITY NUMBER:	304313633
ADMINISTRATOR:	ALGAMA, DONA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 573-1080
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	14	CENSUS: 0	DATE:	07/26/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Dona, Don Algama		TIME COMPLETED:	01:30 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	A Pre-licensing inspection was conducted by Licensing Program Analyst (LPA) Hawkins. LPA met with the applicants Don and Dona Algama. There are three additional adults living in the home. 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. A tour of the home was conducted. This pre-licensing inspection is in response to a change of location application submitted by the licensee. The home is a one story, and has 4 bedrooms and 4 bathrooms. Applicant has designated the following areas of the home as off limits and inaccessible to children: kitchen, garage, 3 bedrooms, 3 bathrooms, laundry room, living room, office, right side of the backyard. These areas were not inaccessible, but applicants stated that they will make these areas inaccessible by utilizing baby gates. Child care will be conducted in the family room and the adjacent bedroom, bathroom. There are age appropriate toys available for children. The fire extinguisher, smoke detector and carbon monoxide detector are within compliance. Applicant's pediatric CPR/First Aid certification is current, and expires 3/2020. Applicant #2 will provide current CPR/First Aid certification. Applicant has completed the 8 hour Preventative health Practices and Nutrition Course. Applicant has documentation of proof of immunization against pertussis, influenza (or written declination), and measles on file. The applicants are owners of the property and will provide documents for the records. Cleaning solutions/chemicals, utensils, and sharp knives are all inaccessible. Poisons/Hazardous items were observed in the backyard area which was accessible. There are no bodies of water on the premises. There are no firearms or ammunition in the home or on the premises however applicant stated that he does own a firearm. Children will use the back patio and gated backyard area as an outdoor play area. Backyard is fully fenced. LPA observed construction debris that could be a potential hazard. Applicant understands the home is to be free from smoking at all times. Applicant understands children are never to be left in a vehicle or unsupervised. Current seat belt law information was provided for applicant. (continued on LIC809C)

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2019

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: ALGAMA, DONA	FACILITY NUMBER: 304313633
	VISIT DATE: 07/26/2019

NARRATIVE

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Staff Records: LIC 508 Criminal Record Statement, LIC 9052 Employee Rights, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse, LIC 9163 Request for LIVESCAN, LIC 9188 Criminal Record Exemption Transfer Request, LIC 9182 Criminal Background Clearance Transfer Request. Required Immunization's, TB test. LIC 311D (copy given)

The home was not incompliance with Title 22 Regulations.

The following items must be completed before a child care license can be issued.
--The following was observed and needs correction before a license can be issued:

1. Backyard area being cleared from debris on the side and back area of the home.
2. Latches on backyard fence (that's used for playground area)
3. Make the off limit rooms and backyard areas inaccessible by fence or other type barriers
4. Applicant Don Algama needs updated Pediatric CPR/First Aid; 8 hours Health & Safety training
5. Child safety knobs for laundry room

Proof of corrections must be completed by 8/26/19 and a follow up inspection will be conducted to ensure compliance. If an extension is needed, please submit a letter in writing before the due date. LPA informed applicant that a final review of the file, will be done before the license is issued.

Report was reviewed and discussed. Exit interview conducted with applicant Don Algama and signed.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2019

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: ALGAMA, DONA	FACILITY NUMBER: 304313633
	VISIT DATE: 07/26/2019

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Continued page 2
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

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, No Johnny jumpers, No bouncers, No exersaucer and any other item that falls into that category are permitted in the facility. Disaster drills, posting requirements, children records, mandated child abuse and injury/death reporting, and criminal records clearances/exemption transfer requests, SIDS and Never Shake a Baby (copy given), Child passenger safety law 2/18(copy given), Earthquake preparedness (copy given), Centralized Complaint and Information Bureau (copy given), and Advocate Program childcareadvocatesprogram@dss.ca.gov . Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org.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/Doucments/SIDSchildcaresafesleep.pdf.

LPA Explained the following sample forms packet:

Children Records: LIC: 700 Identification And Emergency Information, LIC 995E Caregiver Background Check Process, LIC 995A Notification of Parent’s Rights, LIC 627 Consent For Emergency Medical Treatment, LIC 282 Affidavit Regarding Liability Insurance, LIC 9150 Parent Notification, Additional Children in Care. Copies given to applicant.

Facility Records: PUB 394 Notification of Parents Rights, LIC 9040 Facility Roster, LIC 624A Death Report, LIC 6101A Emergency Disaster Plan, LIC 9148 Earthquake Preparedness Checklist, LIC 624B Unusual Incident/Injury Report, and Fire/ Disaster Drill.

Continued on page 3

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2019

LIC809 (FAS) - (06/04)

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