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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409619
Report Date: 08/06/2024
Date Signed: 08/06/2024 11:18:12 AM

Document Has Been Signed on 08/06/2024 11:18 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:ACOSTA FAMILY CHILD CAREFACILITY NUMBER:
197409619
ADMINISTRATOR/
DIRECTOR:		ACOSTA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 470-1487
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
08/06/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:20 AM
MET WITH:Maria Acosta, LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Silva Garibyan conducted a site visit for the purpose of a Required- 3 year visit . LPA met with the licensee and toured the home inside and outside at 7:20AM on 08/06/2024. Licensee was present with five children (including two infants). All areas identified on the facility sketch were inspected. This is a single story 3 bedroom, 2 bathroom home with kitchen, living room, dining area, den, play room, laundry room, and detached garage. Main care is provided in the den and the playroom. Children eat and nap in the den. LPA observed napping equipment, a playpen, small tables and chairs. Off limits areas to the children in care include the living room, dining room, 3 bedrooms, one bathroom, the kitchen, the garage and laundry room located on the left side of the home. Children play on the left side of the home, in front of the garage. Licensee states that she does not park her vehicle in the garage and there is a gate at the entrance of the driveway. There is no pool, spa or other bodies of water on the premises. LPA toured all areas used by children during this inspection. Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption. The bathroom and the kitchen was observed free of chemicals or toxic items that can pose danger to children in care. The outdoor play area was inspected. Children's outdoor play equipment and toys are age appropriate and in good repair.. LPA observed the yard to be fully fenced. The Fire Extinguisher (2A-10-BC) is mounted on the wall in the kitchen. There is a working smoke/carbon monoxide detectors located in the hall way Page 1.
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ACOSTA FAMILY CHILD CARE
FACILITY NUMBER: 197409619
VISIT DATE: 08/06/2024
NARRATIVE
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The First Aid kit was observed and complete. The kitchen door leading to the bathroom utilized by day care children was observed to be locked. LPA observed tables, chairs and napping equipment. Licensee reports she has no firearms or weapons in the home. LPA also observed Licensee's current Pediatric CPR (Adult/Infant /Child), Pediatric First Aid certifications (expire 06/2025) and Mandated Reporter Training (completed on 01/12/2023)
The bathroom and the kitchen was observed free of chemicals or toxic items that can pose danger to children in care. Children play in the side yard. LPA observed the yard to be clean, free of debris, and fully fenced. The fire drills are done twice a year. Last drill was conducted on 5/10/2024. Licensees provide meals and snacks. LPA discuss food preparation, storage and ensuring a log and information regarding dietary restrictions and allergies are kept up to date. Licensees stated that a cell phone with active service in the home will be the main contact number while children are in care.
LPA observed in the play room the Parent Board with all necessary posting required ( Facility License (LIC 203), Emergency Disaster Plan (LIC610A), Notification of Parents' Rights Poster (PUB 394), If You see Something Say Something poster, Car Seat Safety poster). Child Care Facility Roster (LIC9040) was on file.
A review of the children's records was conducted and are found to have the following: LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC702, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization Card. Licensee did not have sleep log and LIC9227 in infant's file.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ACOSTA FAMILY CHILD CARE
FACILITY NUMBER: 197409619
VISIT DATE: 08/06/2024
NARRATIVE
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A review of records indicates that all employees and/or volunteers have immunization records on file for influenza. Licensee is missing records for pertussis and measles. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.



Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
No infants are enrolled at this time. LPA discussed the safe sleep regulations with licensees 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.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ACOSTA FAMILY CHILD CARE
FACILITY NUMBER: 197409619
VISIT DATE: 08/06/2024
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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.

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: https://www.ada.gov/resources/child-care-centers/.

Licensees were informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee Maria Acosta confirmed that there are no Registered Sex Offenders living in the facility.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Maria Acosta.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2024 11:18 AM - It Cannot Be Edited


Created By: Silva Garibyan On 08/06/2024 at 09:46 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ACOSTA FAMILY CHILD CARE
FACILITY NUMBER: 197409619

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in, Licensee is missing TDAP and MMR which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Licensees will send proof of Immunizations via email by due date.
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
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Based on record review, the licensee did not have the completed LIC9227 in the infant's file during inspection. The licensee was not aware of the regulation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee will email the LIC9227 by 08/13/2024 for current infant enrolled that is under 12 months.
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:Betty Bell
LICENSING EVALUATOR NAME:Silva Garibyan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/06/2024 11:18 AM - It Cannot Be Edited


Created By: Silva Garibyan On 08/06/2024 at 09:46 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ACOSTA FAMILY CHILD CARE
FACILITY NUMBER: 197409619

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. There was no documentation or log available by the Licensee for the time of each 15 minute check for the infant, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2024
Plan of Correction
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Licensee will generate a log for the infant enrolled and document the time of each 15 minute check and provide a copy of the log to CCL by the POC due date.
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:Betty Bell
LICENSING EVALUATOR NAME:Silva Garibyan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
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