334845741-11-5-2021-09-CC-EJOS-C85RRS-20211025131538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334845741
Report Date: 10/25/2021
Date Signed: 11/05/2021 09:44:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	GIBBS FAMILY CHILD CARE		FACILITY NUMBER:	334845741
ADMINISTRATOR:	GIBBS,JESSICA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 755-3584
CITY:	EASTVALE	STATE: CA	ZIP CODE:	92880
CAPACITY:	14	CENSUS: 8	DATE:	10/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Jessica Gibbs, Licensee		TIME COMPLETED:	01:20 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	On date and time listed, Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to conduct a annual inspection. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed: Present during the inspection was the Licensee’s Assistant, Jennifer Perault. Normal days and hours of operation are: Sun-Sat 5:00AM-4:00AM OFF-LIMIT AREAS INCLUDE: All of upstairs, garage and Laundry Room The facility is operating within the licensed capacity and appropriate ratios · Appropriate supervision provided during this inspection · A working telephone is present and current number on file · Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection. Both are in working condition. · Fireplace is properly screened to prevent access by children · All hazardous items are stored inaccessible to children · Toxins are locked · Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations · Stairs are barricaded · Verification of control of property on file (Lease) · Property Owner/Landlord Consent (LIC 9149)/Notification (LIC 9151) on file · Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted · Mandated Reporter Training completed 6/8/2021; Assistant’s completed 6/14/2021 · Pediatric CPR and First Aid Card expire on 10/2022, Assistant’s expires 10/2022 · Health & Safety Certificate - completed on 2/4/2007

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: GIBBS FAMILY CHILD CARE	FACILITY NUMBER: 334845741
	VISIT DATE: 10/25/2021

NARRATIVE

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· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age appropriate toys
· Current roster NOT on file
· Documentation of fire and disaster drills on file – Last drill conducted on 7/23/2021
· Children’s records are NOT complete
· Employee’s records are complete
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· Resident and/or staff records reviewed on 10-19-2021 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov
- LPA discussed the safe sleep regulations with Licensee Jessica Gibbs and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
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

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: GIBBS FAMILY CHILD CARE	FACILITY NUMBER: 334845741
	VISIT DATE: 10/25/2021

NARRATIVE

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- Licensee Jessica Gibbs was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

See LIC809-D for cited deficiencies.

The LICENSEE, Jessica Gibbs, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Exit interview conducted and report was reviewed with the Licensee, Jessica Gibbs.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: GIBBS FAMILY CHILD CARE	FACILITY NUMBER: 334845741
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102421(a)

Child's Records

(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the interview and record review, the Licensee did not meet the section cited above which poses a potential Health, Safety & Personal Rights risk to the children in care. During the record review the LPA was unable to review a file for C2. The Licensee stated there was not a file available for review during the inspection.
	POC Due Date: 10/27/2021
	Plan of Correction
1 2 3 4	Licensee agrees to obtain the required documents with signatures and dates for C2. The Licensee will submit the required documents to the Department on or by 10/27/2021.

Type B

Section Cited

CCR

102417(g)(8)

Operation of A Family Child Care Home

(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the interview and record review, the Licensee did not meet the section cited above which poses a potential Health, Safety & Personal Rights risk to the children in care. During the record review the LPA was unable to review a current roster for the facility. The Licensee stated there was not a current roster available for review during the inspection.
	POC Due Date: 10/25/2021
	Plan of Correction
1 2 3 4	Corrected during inspection

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: GIBBS FAMILY CHILD CARE	FACILITY NUMBER: 334845741
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the interview and record review, the Licensee did not meet the section cited above which poses a potential Health, Safety & Personal Rights risk to the children in care. During the record review the LPA was unable to review an LIC 995A for C2 and C6. The Licensee stated there was not an LIC 995A available for C2 and C6 during the inspection.
	POC Due Date: 10/27/2021
	Plan of Correction
1 2 3 4	Licensee agrees to submit an LIC 995A for C2 and C6. The Licensee agrees to submit the LIC 955A for both children to the Department on or by 10-27-2021.

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

LIC809 (FAS) - (06/04)

Page: 6 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: GIBBS FAMILY CHILD CARE	FACILITY NUMBER: 334845741
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(m)(3)

Operation of A Family Child Care Home

(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the interview and record review, the Licensee did not meet the section cited above which poses a potential Health, Safety & Personal Rights risk to the children in care. During the record review the LPA was unable to review an LIC 282 for C2, C7, and C8. The Licensee stated there was not an LIC 282 available for C2, C7, or C8 during the inspection.
	POC Due Date: 10/27/2021
	Plan of Correction
1 2 3 4	Licensee agrees to submit an LIC 282 for C2, C7 and C8 to the Department on or by 10-27-2021.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse Jones	TELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

LIC809 (FAS) - (06/04)

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