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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411753
Report Date: 03/08/2024
Date Signed: 03/08/2024 03:12:04 PM

Document Has Been Signed on 03/08/2024 03:12 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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:POLK FAMILY CHILD CAREFACILITY NUMBER:
197411753
ADMINISTRATOR:POLK, CHARLOTTE ANNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 200-8718
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 14TOTAL ENROLLED CHILDREN: 15CENSUS: 13DATE:
03/08/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee, Charlotte PolkTIME COMPLETED:
03:30 PM
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On March 8, 2024 at 12:30 pm, Licensing Program Analysts (LPA) Angelica Wallin, conducted an unannounced Annual Required Inspection and was met by Licensee, Charlotte Polk. Hours of operation are from Monday to Friday from 5:00 am - 7:00 pm. LPA toured the home inside and outside and a census was taken.

This one - story home consists of 3 bedrooms and 3 bathrooms. Areas used by the children include: living room as isolation room, one restroom, kitchen, dinning room as day care room and front yard. Per Licensee Polk, areas off limits to children include: three bedrooms, two bathrooms, backyard and garage. There are 13 children and 2 staff present during time of inspection. Licensee stated that there are currently 15 children enrolled in the facility. LPA advised license regarding Title 22 regulations concerning ratio and capacity.

The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. LPA noted space with age-appropriate toys. During inspection, LPA observed wall heater in the living room with wooden barricade. There is a working smoke detector and carbon monoxide detector. During inspection, LPA observed fire extinguisher with service date of 12/2023.

LPA inspected kitchen observed cleaning supplies stored with child proof locks in cabinet under the sink. LPA observed knives located in kitchen cabinet on high shelf inaccessible to children in care. LPA observed main childcare bathroom located in the day care room. LPA observed cleaning supplies located on top of medicine cabinet out of reach of children in care. According to the licensee, there are no weapons or firearms at the home; LPA did not observe any firearms or weapons at the time of the inspection. Per licensee, food service is provided. Per licensee, overnight care is not provided at this time. Per licensee, transportation service is provided at this time. LPA discussed with licensee supervision and safety when providing transportation services.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Angelica Wallin
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: POLK FAMILY CHILD CARE
FACILITY NUMBER: 197411753
VISIT DATE: 03/08/2024
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The outdoor play area in the front yard is fenced. LPA observed no hazardous items that can pose a danger to children in front yard. During inspection, licensee informed LPA of small pond located in off-limits backyard area. Per licensee, pond is typically empty, but due to rainy weather is filled with water. LPA observed outdoor pond filled with water. LPA observed outdoor pond barricaded by metal whiteboard easel. LPA consulted with licensee regarding PIN 23-17-CCLD. Per licensee, pond was not part of original facility sketch. Per licensee, pond to be drained of water and inaccessible to children in care. A type B citation issued. Per licensee, front yard is only on-limits outdoor play area. LPA collected updated outdoor facility sketch indicating current on-limit and off-limit areas.

LPA reviewed 6 children’s files and observed files are updated and maintained. A review of staff records indicates that licensee has updated mandated reporter certificate with expiration date of 7/2024 and updated CPR/1st aid certificate with expiration date of 8/2024. Per staff record review, LPA observed two staff with updated CPR/1st aid certificates with expiration dates of 11/2025 and updated mandated reporter certificates with expiration dates of 12/2025 and 6/2025. Per staff record review, LPA observed one staff missing updated immunization record for measles, pertussis, and TB clearance. A type B citation issued. LPA reviewed the following documentation to be kept in facility: facility license, LIC610A, facility fire drill logs, PUB 394, and LIC9040.



Licensee Polk was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family childcare home during the hours of operation. LPA reviewed with Licensee Polk items prohibited in FCCH, no baby bouncers, no infant walkers, No Johnny jumpers, no saucer chairs, and any other item that falls into that category are not permitted in the facility.

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.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Angelica Wallin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: POLK FAMILY CHILD CARE
FACILITY NUMBER: 197411753
VISIT DATE: 03/08/2024
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LPA discussed the safe sleep regulations with licensee Clark and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.

This facility does not provides Incidental Medical Services – IMS. 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/



Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

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.

Exit interview conducted and report was reviewed with licensee, Charlotte Polk. During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Angelica Wallin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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Document Has Been Signed on 03/08/2024 03:12 PM - It Cannot Be Edited


Created By: Angelica Wallin On 03/08/2024 at 02:32 PM
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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: POLK FAMILY CHILD CARE
FACILITY NUMBER: 197411753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation and interview record review, the licensee did not comply with the section cited above outdoor pond filled with water and accessible to children in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Per licensee, outdoor pond to be drained of water and picture evidence of drained pond to be submitted via email. During visit, LPA collected updated outdoor facility skecth of off-limit backyard including outdoor pond.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 in one staff missing immunizatoin record for measles, pertussis and TB clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Per licensee, updated immunization record to be obtained and picture proof as evidence to be submitted via email.
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:Karen Chambers
LICENSING EVALUATOR NAME:Angelica Wallin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


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