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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360918151
Report Date: 06/09/2022
Date Signed: 06/09/2022 02:28:14 PM


Document Has Been Signed on 06/09/2022 02:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:MROSEK FAMILY DAY CAREFACILITY NUMBER:
360918151
ADMINISTRATOR:MROSEK, SUSANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 567-3816
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:14CENSUS: 10DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Licensee Susanna Mrosek TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Zirbes met with Licensee, Susanna Mrosek who guided analyst on a tour of the facility for the One Year Required inspection. This is a single storey house with four bedrooms, two bathrooms, kitchen, dining room, living room, playroom, front and back yard. Per Licensee the living room, kitchen, dining room, hallway bathroom, two bedrooms (located down the hallway, and the back yard are utilized for family child care activities. Per licensee the off-limit areas of the home include the master bedroom, master bathroom, and bedroom located off the living room, laundry room. The off limit areas are inaccessible via key locks and child safety locks. Currently residing in the home are the licensee, and one adult. Upon arrival, LPA observed ten children in care with the Licensee and staff 1 providing supervision. Current days and hours of operation are Monday thru Friday 06:30am- 06:00pm.

Physical Plant: The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds, medicines and hazardous items that can pose a danger to children. According to Licensee all medications are stored in the off limits areas of the home. Sharp knives were stored in the kitchen on a magnetic strip located high on a kitchen cabinet. Cleaning products were located in the off limits areas of the home and in the hallway closet which is equipped with a magnetic lock. The laundry area was made inaccessible via a child safety lock located at least five feet up on the cabinet doors. Fire/earthquake drills was last completed in March 2022. Documentation was maintained and up to date

Safe and age appropriate toys, play equipment and materials were present. The smoke detector and carbon monoxide detector were operable. Per Licensee no one smokes in the home. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment were observed on the premises. The living room is the designated area for ill children in the child care. Report continued on page two
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MROSEK FAMILY DAY CARE
FACILITY NUMBER: 360918151
VISIT DATE: 06/09/2022
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Report continued from page one
Per Licensee, there are zero firearms stored in the home. The home has a wood burning stove located in the living room. According to the Licensee, when the wood burning stove is used the Licensee puts up a gate that surrounds the wood burning stove. The gate is secured to the wall behind the wood burning stove. In addition, there is a wall heater located in the hallway of the home near the bedrooms. The wall heater has a metal grate secured to the unit which made the heating elements inaccessible to the children in care. A child safety gate is located in hallway of the home. The home has swamp cooler. Electrical outlets are inaccessible, and windows cords were inaccessible.

Bathroom: Toilet, sink, faucet, bath/shower were clean and operable. The following are inaccessible: Sharp items, mouthwash, shampoo, razor, nail polish. A changing table was located in the playroom of the home.

Outdoor: The outdoor play area has on limits and off limits areas. The area utilized for child care activities is surrounded by a chain link fence. The outdoor play area was inspected and play equipment was observed to be free of hazards. LPA observed swings, an octagon climber, tiny tikes climbing toys, dramatic play houses, and a mud pit. The climbing equipment was placed on sand and anchored to the ground. LPA reminded the Licensee to regularly monitor the play equipment for potential hazards.

Per Licensee, the family has one dog who is current on their shots. Per Licensee the dog does not interact with the child care children.

CPR/First Aid expires 10/13/2023 and mandated reporter training expires on 7/29/2023.



Review of records to be maintained: LPA reviewed with licensee the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

LPA reviewed ten child files, the Licensees and one staff file during this inspection. Based on LPAs record review four of the ten child files reviewed were missing the LIC 627, Consent for Emergency Medical Treatment. Consent for medical treatment is required to be in the children's records per Regulation 102421(b) Child records, therefore a type B citation was issued, refer to LIC 809D. Per LPAs file review and conversation with the Licensee, Staff 1 has not completed the mandated reporter training. Mandated reporter training is a required training for all staff per Health and Safety Code, 1596.8662(b)(1). A type B citation was issued. All adults living/residing in the home are fingerprint cleared and associated
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MROSEK FAMILY DAY CARE
FACILITY NUMBER: 360918151
VISIT DATE: 06/09/2022
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Report continued from page two

Documents Provided and/or Discussed: Fire Drill Log, Roster, Postings, Safe Sleep, COVID-19 posters. Licensee stated she does not have child care insurance.

The following were observed/discussed and or provided: Notification of Parents' Rights (PUB394), Roster (LIC9040), License, Emergency and Disaster Information (LIC610A, LIC9148).

The following was discussed with the licensee:

Licensee reminded that 100% supervision is required at all times to children in care. Licensee was made aware that it is he/her responsibility to know the regulations as well as anyone who assists in providing care. Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified



The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers, and any other items that fall into that category.

Licensee 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.

PA discussed the safe sleep regulations with licensee 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 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.

Report continued o page four

SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MROSEK FAMILY DAY CARE
FACILITY NUMBER: 360918151
VISIT DATE: 06/09/2022
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Report continued from page three

On January 1, 2018, or before March 30, 2018, a person who is a licensed childcare provider, administrator, or employee of a licensed child day care facility shall complete the online mandated reporter training and shall complete renewal mandated reporter training every two years. @www.mandatereporterca.com.

**Senate Bill AB 633 - Child Care Facilities: Parent Notification Requirements
Summary: This bill amends Health and Safety Code (HSC) sections 1596.859, 1596.8595, 1596.8895, and 1597.05 to improve the transparency of licensing records and to ensure that parents/guardians using a licensed childcare facility are aware of situations that present the greatest danger to children.

§1597.622 Employees or volunteers at family day care home; immunization requirements; records; exemptions (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed - related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication

There is an on-Duty Worker/Officer is available to answer any questions and concerns at
(661) 202-3318. Department hours of operation not including state holidays are Monday - Friday from 8:00am - 5:00pm
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/inspection-process.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/09/2022 02:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: MROSEK FAMILY DAY CARE
FACILITY NUMBER: 360918151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in when Staff 1 did not complete the mandated reporter training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
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Per Licensee, Staff 1 will complete the mandated reporter training. A copy of the training will be submitted to the Department.
Type B
Section Cited
CCR
102421(b)

The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based record review, the licensee did not comply with the section cited above when four of ten child files were missing consent for medical treatment paperwork, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Per Licensee, the consent for medical treatment LIC 627 will be completed by the parents and added to the child record. A copy will be submitted to CCL as proof of completion.

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: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MROSEK FAMILY DAY CARE
FACILITY NUMBER: 360918151
VISIT DATE: 06/09/2022
NARRATIVE
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Report continued from page four

Based on LPA record review there two citations issued today for Child records and Personnel records. In addition one advisory notice was issued.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee Susanna Mrosek.

SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7