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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313701
Report Date: 02/11/2020
Date Signed: 02/11/2020 11:35:39 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:FRASER, MARYAMFACILITY NUMBER:
304313701
ADMINISTRATOR:FRASER, MARYAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 697-8575
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:14CENSUS: 0DATE:
02/11/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Applicant - Maryam FraserTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Corral conducted an announced Pre-licensing inspection of the facility on today's date. LPA Corral toured the facility with the applicant, Maryam Fraser.

A review of the Facility Personnel Report Summary on 02/10/2020 indicates all facility residents, staff, or other individuals who require criminal background check clearances or exemptions. There are 2 adult residents living in the home with 2 children residing in the home. Present in the home during inspection was applicant Maryam Fraser and husband Glenn Fraser. There is 1 pet fish in the home located in the master bedroom in a small size tank. Applicant was informed that any changes to hours and days of operation or changes to facility, including on/off limit areas and change in phone number must be reported to the Licensing Office.

The facility is a single-story home with 3 bedrooms, 2 bathrooms, kitchen, living room, dining room, playroom the backyard and garage. The applicant has designated the playroom, the living room, the first bathroom to the right, and all three bedrooms for napping. The first bedroom is on the right, the second bedroom is on the left and the master bedroom is straight off the hallway. The off-limit areas are the kitchen, the master bathroom and the garage. The kitchen is made inaccessible by placing a gate in the entrance off the playroom and a sliding door that looks off the dining area. The cabinet under the kitchen is made inaccessible by using a magnet lock. The knives were stored in the kitchen counter and made inaccessible by means of the child proof gate and the sliding door. The garage is accessible through the playroom but is made off limits by use of a doorknob safety handle. The master bathroom is also made inaccessible by use of a doorknob safety handle. Applicant is aware that off limits areas must be completely inaccessible during hours of operation.

The backyard is also available for children which contains a slide, a playhouse and basketball hoop. Applicant was advised visual supervision is required during playhouse usage. The facility does have a fireplace in the living room which is properly installed and secured by means of child safety straps on each end. Continue to Page 2.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Eileen CorralTELEPHONE: (714) 743-8354
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2020
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: FRASER, MARYAM
FACILITY NUMBER: 304313701
VISIT DATE: 02/11/2020
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Page 2.
A wall heater or wood stove were not observed to be present in care. Medications are properly stored in the hallway on the highest shelve. Cleaning supplies were stored under the kitchen sink and inaccessible by use of the magnetic locks. Poisons and hazardous items were not stored on site, and none were observed during today’s inspection. Applicant was advised poisonous items must be key or combination locked.

Control of Property was verified by LPA via Rental Agreement. The applicant has a cell phone that is used for child care. The applicant was informed if a cell phone is used for child care, it must remain on the premises at all times during hours of operation. Applicant was advised and acknowledges the home is always to be a smoke free environment.

Body of water was not present in the facility. In the play room toys were observed to be age appropriate and in good condition for the potential ages served. Applicant was advised baby walkers, bouncers, jumpers, and similar items may not be used for children in care. Applicant stated there are no fire arms in the home, applicant was informed that if firearms are present, they must be locked and stored separately from ammunition. During today's inspection at approximately 9:15 a.m. the smoke detector and carbon monoxide were operable, and the fire extinguisher was charged. Applicant’s Pediatric CPR & Pediatric First Aid expire on 10/2021. Applicant completed the 8-hour EMSA Program and Pediatric Preventative Health on 09/29/2019.

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 was discussed with applicant: Individuals who are 18 years of age and older living or working in the home must be fingerprint cleared prior to being present in the facility. LPA provided applicant with website for Live-Scan locations www.oag.ca.gov/fingerprints/locations and informed applicant all adult must complete Live Scan Application (LIC 9163). If adult is fingerprinted cleared and associated to another facility, licensee must submit a Criminal Record Transfer Request (LIC 9182) or Exemption Transfer Request form (LIC 9188).
Continue to Page 3.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Eileen CorralTELEPHONE: (714) 743-8354
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2020
LIC809 (FAS) - (06/04)
Page: 2 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: FRASER, MARYAM
FACILITY NUMBER: 304313701
VISIT DATE: 02/11/2020
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Applicant was also informed to contact Licensing Office (714)703-2800 ask for Personnel ID # and fax Criminal Background Transfer Request form (LIC 9182 or LIC 9188) with a copy of a valid State or Federal Government ID and Criminal Record Statement (LIC 508) to fax # (714)703-2831 prior to hiring adult. Failure to complete the clearance process or license association for any adult resident or assistant will result in a civil penalty assessment against the license. LPA reviewed Unusual Incident Report (UIR) form (LIC 624B) applicant was advised to contact Licensing Office within 24 hours and complete the UIR within seven days by faxing LIC 624B to fax provided above. LPA advised applicant to report any unusual incident or child absence that threatens the physical or emotional health or safety of any child in care.

LPA reviewed with applicant requirements of Disaster Preparedness drills which must be documented every 6 months. LPA advised of Affidavit Regarding Liability Insurance (LIC 282) if liability insurance was not purchase and to maintain the form in the children's files. Car Safety Seat pamphlet was discussed and provided to applicant. Posting requirements were also discussed which include but not limited to Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Parents Rights (PUB 394), Notice of Site Visit (LIC 9213), and License (LIC 203). LPA reviewed with applicant the need to maintain records including but not limited to Children records and Staff/Adults Records (LIC 311D).

Applicant was informed of Mandated Reporter Training for self and all assistants. Department website was provided for applicant to download forms, Title 22 regulations, and training on-line at http://www.ccld.ca.gov. The applicant was also informed to visit the website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov. LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

A copy of “A Child Care Providers Guild to Safe Sleep” was provided to applicant:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP: www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
Continue to Page 4.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Eileen CorralTELEPHONE: (714) 743-8354
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2020
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: FRASER, MARYAM
FACILITY NUMBER: 304313701
VISIT DATE: 02/11/2020
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LPA reviewed with applicant the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult
The applicant was given a pamphlet on Lead Exposure and was discussed with provider. Information regarding E-Learning Modules was also provided and available at https://ccld.childcarevideos.org. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf

Based on today’s inspection and all documentation provided and reviewed, this facility meets licensing requirements and a license for a Large Family Child Care Home will be issued pending Manager final review.

Appeal Rights and Appeal Right process were read and provided to the applicant. Applicant was informed all appeals must be submitted in writing and received by the licensing office within 15 business days.



An exit interview was conducted with Applicant, the report was reviewed and read. The Notice of Site Visit (LIC 9213) was posted and discussed as required by H&S Code Sec. 1596.817. Applicant was informed Notice of Site Visit must be posted where parent’s may view for 30 consecutive days. Failure to post will result in civil penalties of $100.00.

End of Report.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Eileen CorralTELEPHONE: (714) 743-8354
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4