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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195700211
Report Date: 01/11/2024
Date Signed: 01/11/2024 12:27:10 PM

Document Has Been Signed on 01/11/2024 12:27 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:LIBO FAMILY CHILD CAREFACILITY NUMBER:
195700211
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
01/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:JULIA LIBO, APPLICANTTIME COMPLETED:
01:00 PM
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On 01/11/2024, Licensing Program Analyst (LPA) Lisa Clayton conducted an ANNOUNCED PRE-LICENSING INSPECTION with applicant Julia Libo and Alexander Libo. There were no children in care. Hours of operation are Monday through Sunday, 24 hours. Applicants will provide breakfast, lunch, dinner, snacks and water.

The home was toured with the Applicant for a health and safety inspection.

The current facility sketch was reviewed, and LPA confirmed that home consists of the following: living room, kitchen/dining room, enclosed patio, 3 bedrooms, 2 bathrooms, attached garage (accessible through the backyard) and fenced backyard.

The Applicant has requested the following areas be ON-LIMITS: the living room (main day care area), bathroom #1, bedroom #1, bedroom #2, enclosed patio, a portion of fenced back yard. The ISOLATION AREA will be in bedroom #2.

The applicant has requested the OFF-LIMIT AREAS as follows: bedroom #3, bathroom #2, kitchen, attached garage, and both gated areas on the left and right side of the home all of which are inaccessible to children in care by child safety gates, gates, closed and/or locked doors and visual supervision.

Per Applicant, there are no firearms in the home. A copy of the property tax documents were reviewed and shows control of property. Any poisons, detergents/cleaning compounds, medication and hazardous items that can pose a danger to children are inaccessible.

The backyard has a small pond that is fenced in, and in compliance with Title 22 Regulations as it has a five foot fence with a gate that swings away from the pond and has a self-latching device six inches from the top of the fence.


SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: LIBO FAMILY CHILD CARE
FACILITY NUMBER: 195700211
VISIT DATE: 01/11/2024
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The home has a fully charged 3A:40: BC Fire Extinguisher, 2 working smoke detectors, a working carbon monoxide detector, and a carbon monoxide/smoke detector combo. The home has a working telephone and LPA Clayton confirmed the phone number is 818-997-1393. Please report Telephone number changes and/or if you move from home.

Both Applicants CPR/First Aid and Mandated Reporter certificate are current, and they are in compliance with the immunization law which pertains to day care providers.

LPA instructed applicant to review 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.

Safe Sleep Practices were discussed with the Applicant. When putting infants down to nap or long periods of sleep, children must be placed on their backs, in a crib, on a firm mattress with nothing in the crib except for a fitted sheet over the mattress. The child must be physically monitored and documented every 15 minutes, check their temperature, color of skin, and breath.

LPA also informed Applicant 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.

California Law requires Family Child Care Home Applicants to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Roster of the children must be properly maintained, and fire/disaster drill every six months must be documented.

The Applicant was informed of the Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects to disseminate information on the State’s licensing role, provide information to the public and parents on childcare licensing, and provide many other helpful resources to the Applicants and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541


Email: childcareadvocatesprogram@dss.ca.gov
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: LIBO FAMILY CHILD CARE
FACILITY NUMBER: 195700211
VISIT DATE: 01/11/2024
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Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 22-02-CCP. 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
LPA Clayton reminded applicant of the following documents as required in a Family Child Care Home:

CHILDREN'S RECORDS REQUIREMENTS:

· LIC 700 Identification and Emergency Information


· LIC 627 Consent for Emergency Medical Treatment
· LIC 282 Affidavit Regarding Liability Insurance
· LIC 9150 Parent Notification Additional Children in Care
· LIC 9927 Individual Infant Sleeping Plan
· LIC 995A Notification of Parent’s Rights
· Immunization Record

FACILITY RECORDS:
· LIC 624B Unusual Incident/Injury Report
· LIC 9040 Child Care Facility Roster
· LIC 9052 Employee Rights,
· LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
· Proof of current pediatric CPR and First Aid Certificates
· Copy of your deed or lease/rental agreement
· Documentation of Fire and Disaster drills
· Proof of immunizations against pertussis (TDAP), measles (MMR), and influenza
· Mandated Reporter certificate – www.mandatedreporterca.com – must be renewed every two (2) years

FORMS TO BE POSTED


· LIC203 Facility License
· LIC 610A Emergency Disaster Plan
· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: LIBO FAMILY CHILD CARE
FACILITY NUMBER: 195700211
VISIT DATE: 01/11/2024
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In addition, LPA Clayton discussed the following with Applicant:

o There is an effective 24/7 ban on smoking tobacco in a home that is licensed as a family day care home, and in those areas of the family day care home where children are present.
o Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
o Saucer chairs, bouncers, walkers, or any similar items are prohibited.
o All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
o LPA provided and advised the Applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

A complete packet that includes the documents listed above, as well as a ratio flyer, Effects of Lead exposure, PIN 19-02 on Safe Sleep, PIN 19-18 Emergency Disaster, Never Shake a Baby flyer, was emailed to Applicant.

Applicant is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. Applicant was reminded of Departments inspection authority, with or without any notice.

This home is recommended for licensing on 01/11/2024, pending manager approval. This report shall remain of file for 3 years. An exit interview was conducted, and a copy of this report and Notice of site visit was provided to applicant.



An exit interview was conducted, and a copy of this report was provided to applicant Julia Libo.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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