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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364840301
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:13:53 AM

Document Has Been Signed on 05/26/2022 11:13 AM - 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:BOUCHEY FAMILY CHILD CAREFACILITY NUMBER:
364840301
ADMINISTRATOR:BOUCHEY, STEPHANIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 954-4446
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Stephanie BoucheyTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Thompson-Miller met with Licensee, Stephanie Bouchey, who guided analyst on a tour of the facility for an One Year Required inspection. This is a two story 5 bedroom, 3 bathroom home with kitchen/dining, family room, formal dining room, living room, laundry and garage. There is no pool/spa or body of water on the premises. Family members residing in the home include 1 adult (licensee) and no children. Upon arrival LPA observed no children in care. LPA reviewed files for compliance. Licensee is also a foster parent. Licensee is with the San Bernardino County Children and Family Services (foster). Per Licensee, requested to be inactive for two years (foster) Days/Hours of operation are Monday through Sunday 7AM to 5AM. Incidental Medical Services (IMS) policy was discussed.

Physical Plant: The home is clean and orderly. Children have access to the family and living rooms. The home entrance is through the front door. Main care is provided in the living and formal dining rooms and Bedroom #1 (downstairs). Children use the bathroom in hallway. Off limit areas include the entire upstairs (Bedroom #2 , #3, #4, #5/office, bathroom #2 and #3), laundry (washer and dry are locked) and garage (key lock). Per licensee, the garage will be used for activities only (no eating or sleeping). The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (garage cabinet with magnet lock), medicines (upstairs, kitchen cabinet with magnet lock) and hazardous items (sharp knives in upper cabinet of kitchen-magnet lock) that can pose a danger to children.

Fire/earthquake drills complete and maintained current. Roster complete and maintained current. Stairs have a gate. Per Licensee, there are no weapons or firearms on the premise. LPA did not observe any in the home. Home has central AC and heat. The smoke detector and carbon monoxide detector are in operable condition. LPA observed the required fire extinguisher (2A10BC) is fully charged. The facility sketch is complete and current, there is a working telephone (land line and cell).
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 05/26/2022
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Safe and age appropriate toys, play equipment and materials. 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. There are age appropriate napping (cots) equipment. There are no window cords accessible to children.

Bathroom: Free of hazards. The following are inaccessible: Sharp items, mouthwash, shampoo, razor, nail polish. LPA observed hand washing flyer in restroom. Toilet and faucet is clean and operable.

Kitchen: The home has a refrigerator/freezer clean. No chemicals in the kitchen were observed to be accessible. Breakfast, lunch, snacks and dinner will be provided. Hazardous items (sharp knives above the stove) that can pose a danger to children are inaccessible. Cabinets in the kitchen have magnet locks.
Sharp items, plastic bags, cleaning items, no chemicals in the kitchen were observed accessible. The Kitchen cabinets have safety latch. There is a fully stocked refrigerator/freezer. Food brought from the children’s home is labelled and dated.

Outdoor: Backyard (rear and left side) off limits. The backyard is completely fenced. There is no swing/slide. No pets. The left side is gated (separate-wrought iron with gate). There are age appropriate toys. Backyard is clear and clean of debris, fenced and gated all around, no body of water on the premises.

Advisory/Other: First Aid kit was observed with supplies (thermometer) readily available. Licensee has CPR/First Aid 06/14/23 and Mandated Reporter 02/15/2024. 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.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 05/26/2022
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Documents Provided and or Discussed: Fire Drill Log, Roster, Postings, Safe Sleep and Lead Poisoning flyer's, COVID-19 posters and CDPH Mandate (masking update). Licensee stated currently does not have child care insurance.
The following were observed/discussed and or provided: Seat Belt Safety, Safe Sleep poster observed, forms required for children file (LIC311D), Notification of Parents' Rights (PUB394), Roster (LIC9040), License, Staffing and Ratio (capacity limitations handout provided), Emergency and Disaster Information (LIC610A, LIC9148), Lead Flyer Requirement, liability insurance (LIC282) must have signed form on file if no liability insurance. Names of all adults living in the home: All adults living/residing in the home are fingerprint cleared and associated.

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 the Licensee:


Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter (www.mandatedreporterca.com) were reviewed, to be completed every two years; Licensee reminded that 100% supervision is required at all times to children in care; Licensee made aware that it is his/her/their 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; Regulation prohibits the smoking of any kind during the operation of the day care. Licensee currently does not have Child Care Insurance. Per Licensee no on smokes in the home. The "Notification of Parent's Rights" poster must be posted in an area of the home accessible to parents. Licensee advised how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 05/26/2022
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Licensee advised of the requirement to report Unusual Incidents. Licensee informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above.

Licensee advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to part obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

Prior to making alterations or additions to a family child care home or grounds, the Licensee shall notify the Department of the proposed changed, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "child care" room; Room additions to the family child care home. Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. Licensee shall provide the Department with a copy of an inspection report when an inspection is required by the local building inspector as a result of the alteration, addition or construction.

FCCH
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.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 05/26/2022
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Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. The Licensee shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of family child care laws or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

LPA discussed the safe sleep regulations with licensee's and also instructed Licensee to visit 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's 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.
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.

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.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 05/26/2022
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PIN 22-01-CCLD Dated 5/23/22
Individuals who hold a criminal record clearance or exemption must notify the Department within ten (10) calendar days of any change to their mailing address to ensure effective communication related to a criminal record clearance or exemption. Providers and Licensees are encouraged to ensure individuals on their employee/staff rosters are aware of this new requirement.
Individuals may update their mailing address with the Department in various ways, including: logging into their Guardian account; sending an email to Guardian@dss.ca.gov; calling the customer service line at 888-422-5669; sending a request to update by fax at (916) 754-4589; or mailing the address change information to:
Care Provider Management Bureau
744 P Street MS T9-15-62
Sacramento, CA 95814
If you have questions regarding this PIN, please contact CPMB at 888-422-5669 or Guardian@dss.ca.gov for assistance.
The Department will convey all new information through PINs. Please sign up to be notified here and visit the Department’s website for the latest PINs.

Notice of Site Visit: A notice of site visit was given and must remain posted for 30 days. Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

No deficiency. The On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm. Exit interview conducted and report was reviewed with Licensee Stephanie Bouchey. This report was read and provided to Licensee Stephanie Bouchey on this date
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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