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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192004702
Report Date: 07/21/2022
Date Signed: 07/21/2022 12:34:29 PM

Document Has Been Signed on 07/21/2022 12:34 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:PUGH FAMILY CHILD CAREFACILITY NUMBER:
192004702
ADMINISTRATOR:PUGH, SHELONDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 547-6076
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:Shelonda PughTIME COMPLETED:
10:30 AM
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On 7/21/2022, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required 1 Year inspection at the Pugh Family Child Care. Upon arrival, the LPA met with the licensee, Shelonda Pugh who guided the LPA on a tour of the facility. Family members residing in the home include Two adults, (Licensee and her daughter). Per LIS, facility annual fees are current. All adults living in the home have been background cleared. Per licensee, the hours of operation are Monday through Friday 6:00 a.m. to 11:00 p.m ( will vary based upon parent schedule). During this inspection, there were 0 day-care children present. Incidental Medical Services (IMS) were discussed.

The Home is set up as follows:
This is a two-story 4 bedroom, 3 bathroom home with a kitchen, living room, formal dining room, laundry room, family room, and garage. There is no pool, spa, or other bodies of water on the premises. The home was inspected for safety, comfort, cleanliness, telephone service, central air, and heat and ventilation. The home has central heating and air conditioning. All windows have screens and are free of cracks, bugs, and debris.

Ø Main Area: Main care is provided in the family, living (front entrance), and formal dining rooms. Children use the bathroom located next to the family room. Children have access to the backyard.
· Living Room / Family room/Formal Dining Room: In the areas, LPA observed a fireplace that was properly screened via a mirror glass barrier which made it inaccessible to children. LPA observed age-appropriate toys and furniture for the children. LPA observed: A small table was observed with a total of eight chairs. Several plastic storage bins were observed in which games and toys are stored for the children. A small play kitchen was located by the door with which children can play. There are games and books on the premises of this facility. There are mats on the floor that have educational/learning activities on them. The mats were observed to be in good condition.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2022
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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Document Has Been Signed on 07/21/2022 12:34 PM - It Cannot Be Edited


Created By: Carol Heath On 07/21/2022 at 09:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(6)
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: (6) Outdoor play areas shall be either fenced, or outdoor play areas shall be supervised by the licensee Section 102417(g)(5).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA observed the backyard wood fences are not stable.and several BBQs in the backyard, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2022
Plan of Correction
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The Licensee will fix the backyard and the fences and text the LPA the pictures.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Claretta Yates
LICENSING EVALUATOR NAME:Carol Heath
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


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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: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 07/21/2022
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· Children Bathroom (#1): Children use the bathroom next to the family room. The Bathroom was toured and inspected sink/toilet is in operable condition. Toilet and faucets are clean, safe, and operable. No poison and medications are in the sink cabinet and drawers. The bathroom was observed to be free and clear of hazardous items. The bathroom was clean, sanitized, and in good repair.
· items were inaccessible to children (Safety latches). In the kitchen, all sharp utensils, poisons, and medications are made inaccessible to children on the hight cabinet.
Ø Backyard: The backyard was inspected; The backyard has fence all around. However, there most of the wood fences are not stable. On the right site the backyard, LPA observed several BBQs , a landmore and several braken toys. In the backyard, there is a storage shed without the lock. The outdoor play area was observed to be free of hazards, and loose and sharp parts. The licensee signed the Declaration. She will not allow any daycare children to go to the backyard until the backyard is organize and repair the wood fences.
Ø Off-limit: Off-limit areas include the home's entire upstairs (3 bedrooms, 2 bathrooms), laundry area (downstairs bedroom in laundry area), and the garage. Stairs have a gate.
Ø Others:
· AC/Heating Unit was observed. AC/Heating Unit is located on the right side of the home and is inaccessible to children via barrels blocking access to the unit.
· Bodies of water: Per the licensee, there are no bodies of water in the home.
· Electrical outlets: All unused electrical outlets are plugged in and made inaccessible to children.
· Fire extinguisher (2A10BC): LPA observed there is a required fire extinguisher (2A10BC) fully charged Date: 10/2021 and located in the kitchen inaccessible to children. It meets standards established by the State Fire Marshall.
· Fireplace: The fireplace was observed in the Family room and is screened to make it inaccessible to the children.
· Hanging window blind cords: The cords are inaccessible to children.
· Incidental Medical Services (IMS): 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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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: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 07/21/2022
NARRATIVE
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Licensee will not be providing IMS to the children.
· Isolation area (Illness): Per licensee, if the child shows signs of illness, he/she will be separated from other children and stay in Family Room.
· Medications and cleaning solutions: Detergents/cleaning compounds are in the off-limit garage. Medications are in the upper kitchen cabinet.
· Napping: Children will nap in the designated nap areas with adult supervision. Pre licensee, she only has school age chidren, so they do not take nap.
· Overnight Care: Pre licensee, she does not provide overnight care.
· Pets: 1 cat and has current vaccinations.
· Phone service: There is a working landline or cell phone
· Smoke Detectors and Carbon Monoxide: The smoke detectors and carbon monoxide devices tested operable.
· Stairs: There is a safety gate or barricaded to make the stairs inaccessible to the children.
· The First Aid kit is located in the kitchen inaccessible to children. The First Aid Kit was observed complete with supplies, but LPA did not observe a first aid manual.
· Transportation: The licensee does provide transportation for children. The licensee has a valid California driver's license with an expiration date of 01/20/2025. The licensee has valid vehicle insurance with the expiration date of 12/21/2022 and vehicle registration dated 01/08/23.
· Weapons or Firearms: Per Licensee, there are no Firearms at the facility at this time. LPA does not observe any firearms.
Ø Documentation:
· Child files: LPA observed 4 children's files contained all required licensing documents.
· CPR/First Aid: LPA observed licensee has current Pediatric CPR and First Aid Training with expiration date (07/10/2023) 1 hour of nutrition training, (8) hours of Preventive Health and Safety Training.
· Criminal Record: Pre Guardian, all adults live in this facility obtain a criminal record clearance.
· Facility fees: Per Licensing Information System, facility annual fees were current.
· Fire Drill and Disaster Drill: Per the licensee, fire and disaster drills are conducted every 6 months; the last drill was documented and conducted on 07/12/2022.
· Immunization: The licensee and her assistant have the required immunizations (MMR and DTaP). The licensee and her assistant provided a written statement declining the influenza vaccination.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 07/21/2022
NARRATIVE
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· Infant Sleeping Plan (LIC 9227) and Sleeping Log: LPA shared the information with the licensee. Per Licensee, there is NO infant (0-12 months) enrolled in the facility.
· Licensee has posted as required the Facility License, Emergency Disaster plan, Earthquake Preparedness and Parents Rights Poster
· Mandated Reporter Training: The licensee has completed and renewal the online mandated reporter training at www.mandatedreporterca.com on 7/16/2023
· Staff Personnel File: Pre licensee, she does not have a assistant right now.
· Staffing Ratio and Capacity: This is Large family childcare facility. LPA observed 0 children during the inspection.

Ø The following information was discussed with the licensee:
ü Mandatory Forms for the children’s files and provider’s files.
ü Requirements for fire drills, earthquake drills, and documentation for both.
ü The role and responsibilities of being a mandated reporter were discussed.
ü The licensee is reminded that 100% supervision is required for children at all times.
ü Capacity requirements, Roster requirements, Posting requirements, Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children’s files and provider’s files, and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. The licensee was reminded that supervision is always required for children in care.
ü Licensee was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care. Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified.
ü Licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B
ü The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also, call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 07/21/2022
NARRATIVE
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ü Criminal Record Statement: Licensee [or facility representative] 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 the 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.
ü Safe Sleep: LPA discussed the safe sleep regulations with licensee [or facility representative] 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.
ü Notice of Site Visit: A notice of site visit was given and must remain posted for 30 days.
ü Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
ü Type A citation: LPA (name of analyst) informed licensee [or facility representative] (include name) that this report dated (insert visit date) document(s) (number of Type A citation) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA (name of analyst) informed the licensee [or facility representative] to provide a copy of this licensing report dated (insert visit date) that documents any Type A citation(s) 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.
ü 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.
ü --Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 07/21/2022
NARRATIVE
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n Our Quarterly updates come out every 3 months they are also now in Spanish please log in to the CCLD website or you can email our advocates to have the quarterly updates sent directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

ü The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 AM - 5:00 PM.

ü A copy of the Safe Sleep Proposed Regulations was provided to Licensee.

ü LPA provided consultation during the inspection.

Deficiencies cited: (See LIC 809D). The following Type B deficiencies are being cited in accordance with Title 22 of the California Code of Regulations and/or Health & Safety codes.



Exit interview conducted and the report was reviewed with the licensee Shelonda Pugh.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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