376622338-11-18-2022-20-CC-ECAA-CL9MBV-20221117082833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376622338
Report Date: 11/16/2022
Date Signed: 11/18/2022 11:35:46 AM

Document Has Been Signed on 11/18/2022 11:35 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/18/2022 10:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

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 November 16, 2022 at 09:15 am, Licensing Program Analyst (LPA) Edgar Campana conducted an unannounced Annual Inspection and met with the Licensee, Yvonne Forbes. LPA disclosed the purpose of the inspection and were granted entry into the facility by the Licensee. Nine (9) children and two assistants were present in the facility during this inspection. This facility is a two story, five (5) bedroom, five (5) bathroom house. Licensee accompanied LPA inside the facility during this inspection. The following areas used for child care are: living room, family room, daycare bathroom in hallway, dining room, and kitchen. Off limits areas include: Entire second floor (and backyard effective as of the writing of this report). Licensee was reminded that Garage is not to be used as a daycare room. The fire extinguisher (rated 3A-40 BC), smoke detector, and carbon monoxide detector met requirements. All hazardous items were made inaccessible to children. The licensee has toys, play equipment and materials available. A waterfall area in the backyard was observed with approximately 2-3 inches of water during the inspection; backyard was previously designated for daycare use. Licensee stated that she will make backyard off-limits and LPA informed Licensee of process. Licensee stated that body of water will be made inaccessible. Licensee stated there are no weapons in the home. A review of staff records on this date indicates that one facility assistant does not have criminal record and child abuse clearances or exemptions. Licensee stated that assistant only works one or two days a month during emergency situations. LPA explained to Licensee that all assistants over the age of 18 are required to have a criminal record clearance regardless of how often they work at the facility. This is an amended version of a report that was created on 11/16/2022

SUPERVISOR'S NAME: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Edgar Campana	TELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: FORBES, YVONNE FAMILY CHILD CARE	FACILITY NUMBER: 376622338
	VISIT DATE: 11/16/2022

NARRATIVE

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Licensee’s First Aid and CPR certifications expire on 08/2023. Licensee has required immunizations. Licensee does not have Mandated Reporter Training certificate on file; Licensee stated that she was not aware of Mandated Reporter training requirements and LPA provided training link. Facility roster was not available for review. Fire and disaster drills have not been conducted. Cribs or play yards were not free from all loose articles and objects, as two stuffed animals and a small cloth towel were observed in a crib were infant was sleeping. The provider physically checks on sleeping infants every 15 minutes, yet documentation was not being maintained.

LPA 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.

LPA provided and discussed the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, and ensure that all adults residing or working in the home have criminal background clearances or exemptions. Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare. Licensee was also provided handouts with information regarding Safe Sleep Regulations/SIDS, Lead exposure and Shaken Baby Syndrome. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA discussed and provided Licensee with the following: child care advocates email address: childcareadvocatesprogram@dss.ca.gov . In addition, for general questions or questions regarding licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.

SUPERVISOR'S NAME: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Edgar Campana	TELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: FORBES, YVONNE FAMILY CHILD CARE	FACILITY NUMBER: 376622338
	VISIT DATE: 11/16/2022

NARRATIVE

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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 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.

LPA Edgar Campana informed licensee Yvonne Forbes that this report dated 11/16/2022 documents 4 Type A citations which shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.

Also, LPA Edgar Campana informed the licensee to provide a copy of this licensing report dated 11/16/2022 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A copy of this report and appeal rights (LIC 9058) were provided to the licensee. A Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted in Spanish and report was reviewed with the licensee, Yvonne Forbes.

**This is an amended version of a report that was created on 11/16/2022**

SUPERVISOR'S NAME: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Edgar Campana	TELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/17/2022 08:29 AM - 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: FORBES, YVONNE FAMILY CHILD CARE	FACILITY NUMBER: 376622338
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102417(g)(3)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above in that staircase was not barricaded, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2022
	Plan of Correction
1 2 3 4	Licensee stated that she will place barricade staircase by 11/17/22 and provide proof to Department.

Type A

Section Cited

CCR

102425(b)(2)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. (2) Bumper pads shall not be used. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in, as a crib was observed with bumper pads while an infant was sleeping inside, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2022
	Plan of Correction
1 2 3 4	Licensee removed bumper pads. Licensee given Infant Safe Sleep information. Licensee stated that she will watch videos of safe sleep on CCLD website will provide Department with summary by 11/24/22.

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: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Edgar Campana	TELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/18/2022 11:40 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/18/2022 10:22 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: FORBES, YVONNE FAMILY CHILD CARE	FACILITY NUMBER: 376622338
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(10)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as there was a baby walker in the garage which Licensee stated is used by a daycare child, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2022
	Plan of Correction
1 2 3 4	Licensee was given copy of prohibited items in daycare settings. Licensee stated that she will remove prohibited items by 11/16/22.

Type B

Section Cited

CCR

102417(g)(5)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in that waterfall area (pond) had approximately 2-3 inches of water, which poses/posed an immediatel health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2022
	Plan of Correction
1 2 3 4	DEFICIENCY CHANGED TO TYPE A Licensee stated that body of water will be made inaccessible and proof will be provided to Department by COB 11/18/22. This is an amended version of a report that was created on 11/16/2022

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: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Edgar Campana	TELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/17/2022 08:29 AM - 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: FORBES, YVONNE FAMILY CHILD CARE	FACILITY NUMBER: 376622338
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2022

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
1 2 3 4	Based on record review the licensee did not comply with the section cited above as sleep logs were not being maintined, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/25/2022
	Plan of Correction
1 2 3 4	Licensee stated that she will review regulations and provide proof of logs to Department by 11/25/22

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as an LIC9227 was no on file for infant in care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/25/2022
	Plan of Correction
1 2 3 4	Licensee stated that she will provide proof of completed LIC9227 to Department by 11/25/22

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: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Edgar Campana	TELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/17/2022 08:29 AM - 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: FORBES, YVONNE FAMILY CHILD CARE	FACILITY NUMBER: 376622338
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102370(d)(1)

Criminal Record Clearance

(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as an assistant working in the facility did not have a criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2022
	Plan of Correction
1 2 3 4	Licensee stated that assistant will not be allowed to work at facility unless they have a criminal background check clearance.

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: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Edgar Campana	TELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC809 (FAS) - (06/04)

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