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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845902
Report Date: 09/23/2021
Date Signed: 09/30/2021 09:21:34 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:BOLDEN FAMILY CHILD CAREFACILITY NUMBER:
334845902
ADMINISTRATOR:BOLDEN,ANGELA & LAKEISHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 957-5028
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:14CENSUS: 7DATE:
09/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Lakeisha Bolden, LicenseeTIME COMPLETED:
12:22 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to conduct an annual inspection. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:
Normal days and hours of operation are: Monday-Friday, 6:00AM-6:30PM

OFF-LIMIT AREAS INCLUDE: All of upstairs, Garage, Bedroom #1, Downstairs storage closet, Kitchen. Office was put on limits effective 9/23/2021.

Clearance granted 8/12/2020

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 rated 2A:10B:C, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.

· No fireplace

· 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

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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: BOLDEN FAMILY CHILD CARE
FACILITY NUMBER: 334845902
VISIT DATE: 09/23/2021
NARRATIVE
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· Stairs are barricaded

· Verification of control of property on file

· 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- Angela 8/14/2020, Lakeisha 4/2/2018

· Pediatric CPR and First Aid Card expires on Angela 8/2022, Lakeisha 8/2022

· Health & Safety Certificate - completed on 6/2020

· 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 on file

· Documentation of fire and disaster drills on file – Last drill conducted on 6/7/2021

· Children’s records are complete

· No employees

· 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 9/23/2021 indicate that all adults who require

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC809 (FAS) - (06/04)
Page: 2 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: BOLDEN FAMILY CHILD CARE
FACILITY NUMBER: 334845902
VISIT DATE: 09/23/2021
NARRATIVE
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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, Lakeisha Bolden, 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

- Licensee Lakeisha Bolden 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

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC809 (FAS) - (06/04)
Page: 5 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: BOLDEN FAMILY CHILD CARE
FACILITY NUMBER: 334845902
VISIT DATE: 09/23/2021
NARRATIVE
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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, Lakeisha Bolden, 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, Lakeisha Bolden.

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

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC809 (FAS) - (06/04)
Page: 3 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: BOLDEN FAMILY CHILD CARE
FACILITY NUMBER: 334845902
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the interview/record review, the Licensee did not meet Safe Sleep regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. During the inspection the Licensee stated the infants are checked on while sleeping but there are no sleep logs available for review for C1, C2 and C3.
POC Due Date: 09/24/2021
Plan of Correction
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Licensee agrees to send a sleep log to te Department by 9/24/2021. Licensee also agrees to ensure all children who require a sleep log have one on file.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the interview/record review, the Licensee did not meet Immunizations regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. During the inspection the Licensee stated C1, C2 does not have immunizations available for review.
POC Due Date: 09/30/2021
Plan of Correction
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Licensee agrees to submit immunization records for C1 and C2 by 9/30/2021. Licensee also agrees to ensure all children enrolled have immunizations on file.
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 RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2021
LIC809 (FAS) - (06/04)
Page: 4 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: BOLDEN FAMILY CHILD CARE
FACILITY NUMBER: 334845902
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2021

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
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Based on the interview/record review, the Licensee did not meet Immunizations regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. During the inspection the Licensee stated C7 does not have a file available for review.
POC Due Date: 09/30/2021
Plan of Correction
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Licensee agrees to submit a completed file for C7 to the Department by 9/30/2021. Licensee also agrees to ensure all children have a file available for review with all required licensing forms.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the interview/record review, the Licensee did not meet Safe Sleep regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. During the inspection the Licensee stated there is not an LIC 9227 available for review for C1
POC Due Date: 09/24/2021
Plan of Correction
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Licensee agrees to submit an LIC 9227 for C1 to the Department by 9/24/2021. Licensee also agrees to ensure that all children who require an LIC 9227 have one on file.
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 RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2021
LIC809 (FAS) - (06/04)
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