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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376300333
Report Date: 02/23/2022
Date Signed: 02/23/2022 12:48:49 PM


Document Has Been Signed on 02/23/2022 12:48 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501



FACILITY NAME:ASHWORTH FAMILY CHILD CAREFACILITY NUMBER:
376300333
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
02/23/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Dennis and Kumiko AshworthTIME COMPLETED:
01:00 PM
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On the above date and time, Licensing Program Analyst (LPA) Andrea Taylor, for the purpose of conducting a Case Management Inspection at the request of the Licensees Dennis and Kumiko Ashworth. The licensees requested to increase capacity from a small family child care to a large family child care. LPA arrived at the home to find the home requires a gate to be opened by licensee to gain enterance to the property. LPA called the licensee who promptly opened the gate allowing LPA on to the property. Licensee Dennis Ashworth met LPA outside the home and invited LPA in to the home. Present were 2 adult residents. A census was taken: 4 children present.
A fire clearance was approved on 2/15/22
LPA toured the facility, inside and out and the following was observed and/or discussed:
Normal days and hours of operation are: Monday - Friday 7:15 AM to 5:30 PM
OFF-LIMIT AREAS INCLUDE: whole house except playroom at the back of the home, living room in the front of home and dining room next to the living room.
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector are present and were tested by the applicant during this inspection. Fire extinguisher, smoke detector and carbon monoxide detector are in working order.
· Licensee records were up to date CPR/1st Aid Certificate expires 10/13/2022
Mandated Reporter certificate expires 3/20/23.
· Children's records were reviewed.
· Last Fire Drill: 02/05/2022.
All mandated postings were up for public view.
· License stated no guns or weapons present as of 02/22/2022. Applicant understands all guns, weapons and ammunition must be key-locked separately and made inaccessible per Title 22 Regulations.
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Andrea TaylorTELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: ASHWORTH FAMILY CHILD CARE
FACILITY NUMBER: 376300333
VISIT DATE: 02/23/2022
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· Criminal record clearances are required prior to all adults living or working in a Family Child Care Home. A civil penalty of $100.00 per day the person has been present, may be assessed. Resident and/or staff records reviewed on 02/22/2022 indicate that all adults who require caregiver background checks have received all required clearances or exemptions
Baby walkers, bouncy seats, exer-saucers, swings and other similar items are prohibited
- The applicant is urged to visit the U.S. Consumer Product Safety Commission web page at www.cpsc.gov to ensure that equipment purchased for the day care has not been recalled
· There are no bodies of water as of this date. Applicant understands all bodies of water including ponds, above ground pools and spas, in-ground pools and 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 when not in use.
· Clean, safe and age appropriate toys.
· There are no toxic plants observed at this time.
· The Applicant was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov
· Issued applicant the following: SIDS information and Shaken Baby Syndrome pamphlet – For more information on SIDS and Safe Sleep Environments, please visit:
California Department of Public Health – California SIDS Program: http://www.cdph.ca.gov/programs/SIDS/pages/default.aspx
AAP – Safe Sleep Campaign: http://www.healthychildcare.org/sids/html
AAP-Free Training: Reducing the Risk of SIDS in Early Education and Child Care: http://shop.aap.org/Reducing-the-Risk-of-SIDS-in-Early-Education-and-Child-Care
And Caring for our Children, Safe Sleep Practices and SIDS/Suffocation Risk Reduction: http://cfoc/nrckids/org/standardview/spccol/safe_sleep
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Andrea TaylorTELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: ASHWORTH FAMILY CHILD CARE
FACILITY NUMBER: 376300333
VISIT DATE: 02/23/2022
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· The licensee does not have Incidental Medical Services (IMS) plan and 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



An exit interview was conducted. Appeal rights and report were discussed.
The Notice of Site Visit must be posted at the entrance of the facility for a period of
30 days. If a serious violation is cited, a copy of the licensing report (LIC809/LIC9099) must also
be posted for 30 days. A civil penalty of $100 per violation will be assessed for noncompliance.
During the exit interview, the Licensees Dennis and Kumiko Ashworth, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Andrea TaylorTELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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