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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197413734
Report Date: 08/09/2022
Date Signed: 08/17/2022 06:43:14 PM

Document Has Been Signed on 08/17/2022 06:43 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:BALLENA FAMILY CHILD CAREFACILITY NUMBER:
197413734
ADMINISTRATOR:BALLENA, CYNTHIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 729-5917
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cynthia BallenaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) King-Lewis conducted a required 1 year Inspection with licensee. LPA observed 2 preschool children (4 & 3) and 1 infant( 1yrs 7 mos.) in care with 3 staff. LPA was guided on a tour of the home day-care area. The day care take place in the following area of the home: Living room, family room, dining area hallway bathroom, bedroom #1, and rear yard.

Licensee states the day care hours of operation is Sunday - Saturday 24 hours. Currently living in the home is the licensee.

Physical Plant:
There are no body of water on the premises. Licensee stated there are no firearms or other dangerous weapons. Medication are stored in kitchen pantry. Licensee stated no children currently on medication. Detergents, cleaning compounds, poisons and other items which could pose a danger to children are inaccessible to children stored in off limit laundry area and garage secured with a kiddy knobs. No fireplace observed in the home. Fire extinguishers, smoke detectors, and carbon monoxide are operable at time of inspection. LPA observed the home to be orderly, central air and heating available. The licensee uses a cell phone for the license day care and land line available. Licensee was advised the cell phone shall be charged and available during daycare hours.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BALLENA FAMILY CHILD CARE
FACILITY NUMBER: 197413734
VISIT DATE: 08/09/2022
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LPA discussed safe sleep regulation and informed licensee to refer to regulation 102425(J) for documentation requirement. LPA reviewed requirement with licensee during this inspection. Licensee shall supervise infants while they are sleeping by physically checking every 15 minutes and documenting the child status in writing. Licensee was informed all infants shall have an individual infant Sleeping Plan (LIC 9227). Licensee aware no infant shall be swaddle, car seat shall not be used for sleeping, LPA provided Child Care Licensing Safe Sleep webpage as an additional resource: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep

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. To provide Incidental Medical Services, such as administering blood glucose monitoring, inhaled medications, Epi-pen and Epi-pen Jr., insulin shots, gastrostomy tube feeding and care, or carrying out other medical orders, it is best practice to complete a “Plan for Providing Incidental Medical Services”. This plan will help you ensure that you can provide this service in the safest manner possible. A Plan for Providing IMS must be submitted to the Department.

Each child care licensee is responsible for determining their legal obligations under the ADA and California disability laws. Information regarding ADA: 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
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
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: BALLENA FAMILY CHILD CARE
FACILITY NUMBER: 197413734
VISIT DATE: 08/09/2022
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Care and Supervision
Licensee is aware she must be present in the home and shall ensure that children in care are supervised at all times. Licensee stated no transportation provided for day care children. LPA informed licensee to make sure the transportation vehicle is proper insured to transport day care children prior to providing transportation. Licensee is aware the capacity stated on the facility license shall be the maximum number of children being cared for at one time.

Facility Records Review
LPA observed current facility roster of children, and current fire, disaster drill. Licensees mandated reporter training certificate expired on 02-19-24 and Licensee CPR and first aid card expires 05-12-2023. Licensee is aware that all employees or volunteer at the day-care shall be immunized against pertussis and measles and maybe immunized against influenza, and show proof of negative TB result within first year of being present in the home.

Facility Administration
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.

Licensee aware to immediately remove individual and prevent individual for returning to the home or having contact with children in care upon notice from the department to remove an individual.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
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: BALLENA FAMILY CHILD CARE
FACILITY NUMBER: 197413734
VISIT DATE: 08/09/2022
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Licensee is aware any authorized employee of the Department may enter and inspect any place providing personal care and services at any time with or without advance notice. Licensee is aware other personnel shall complete training on preventive health practices including CPR and first aid per regulation 102416 (c).

Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in writing within 7 day of incident on the form LIC624B per the regulation. The report unusual incident/injuries report should be emailed to UnusualIncidentReport@dss.ca.gov

During this inspection facility was observed to be in compliance with Title 22.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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 the licensee a copy of this report and a notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
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