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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414408
Report Date: 01/27/2025
Date Signed: 01/27/2025 04:12:07 PM

Document Has Been Signed on 01/27/2025 04:12 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
197414408
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, SYLVIA J.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 465-3733
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
01/27/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Licensee Sylvia HernandezTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 12/11/24 at 8:10am Licensing Program Analyst (LPA), Jeanine Lipsey conducted an unannounced Required Annual Inspection and was met by Licensee Sylvia Hernandez. An Entrance checklist was provided. LPA observed twelve children in care being supervised by 3 staff. Capacity as specified on the license is being maintained. Days and hours of operation are Monday through Friday 5am to 8 pm. (LIC) 282- Affidavit Regarding Liability Insurance was observed in the children’s files.

LPA observed the following required postings: License, PUB 394 Notification of Parents’ Rights Poster, and LIC 9148 Earthquake Preparedness Checklist. LPA advised all LIC9213 Notice of Site Visits shall be posted for 30 days after each site visit. LPA advised, any licensing report documenting a Type A citation must be posted for 30 days. LPA advised LIC610A Emergency Disaster Plan and a disaster/fire drill log shall be available to view with disaster drills completed at lease every six months. The last disaster drills were conducted on 8/21/24.

LPA toured the home inside and outside. The home is a single story, 3-bedroom, 2 bathrooms, with 2 living rooms, dining room, and kitchen with detached garage turned into living quarters. An adult fingerprint cleared person lives there. The areas that are accessible to children: are 2 living rooms, dining room, #1 bathroom, the front yard for outdoor activities. The isolation area will be located in the Livingroom closes to the front door.

LPA did not observe any poisons resent during the inspection. Detergents, cleaning compounds, medication and other hazardous item were made inaccessible to children. Per Licensee, there are no firearms, weapons. LPA observed the home to be free from defects or conditions which may endanger the children. Safety locks were installed for the off-limit cabinets and drawers. Off limit areas were made off limit by child gate. LPA observed a fire place barricaded by a peace of wood and children toy cubbies.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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 01/27/2025 04:12 PM - It Cannot Be Edited


Created By: Jeanine Lipsey On 01/27/2025 at 01:19 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 197414408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.814(a)(1)(A)(i)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (1) The swimming pool shall be equipped with, at minimum, the following drowning prevention safety features: (A) An enclosure, including, but not limited to, a fence, wall, or other barrier that isolates the swimming pool from access to the family daycare home and has all of the following characteristics: (i) An access gate that opens away from the swimming pool and is self-closing with a self-latching, key lockable device placed no lower than 60 inches above the ground.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in that The mesh fencing is not attached to the wall to prevent a child from entering. The door does not self lock or close, must have a pool cover or alarm, 17' US coast guard life ring, 12 foot recue pole with body hook, daily inspection of drowning prevention safety features, all items must have documentation from the American Society for Testing and Materials (ASTM) international standards which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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Licensee will purchase all items, fix the fence and send proof of documentation by 2/25/26.
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:Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 197414408
VISIT DATE: 01/27/2025
NARRATIVE
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LPA observed fully stocked first aid kit. LPA Lipsey observed a working carbon monoxide/smoke detector in both living rooms, LPA was able to hear a successful test. Fire extinguisher 2A10BC was observed and located in the kitchen and was purchased on 1/27/25. Electrical outlets were observed to be inaccessible to children in care with electrical plugs. The home was observed to be clean and orderly with heating and ventilation. LPA observed safe toys, play equipment, and materials. LPA verified the home has a working cell service.

LPA observed the outdoor area to be fenced and free from hazards LPA observed multiple play equipment in good repair. Licensee ensures that children in care are always supervised. LPA observed a pool in the back yard. LPA toured the backyard area to ensure that the pool meets the Title 22 requirements. The licensee does not have at least one of the following: An approved safety pool cover that is manually or power operated and meets the performance standards of ASTM International Standard F1346-23, Or An alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water. The alarm shall be turned on and be in working condition during a facility’s operating hours while the swimming pool is not in use. Licensee was advised that they shall maintain and make available for inspection, upon request by the department, documentation that establishes the alarm is compliant with ASTM International Standard F2208.

LPA observed the pool fencing to be 5 feet high, have a self-latching gate that swing away from the pool and have a self-latching device that is located no more than 6 inches from the top of the fence. Per licensee, the door did not self lock or close due the recent winds that damage the fence. The mesh fencing covers the pool on 1 side. The other three sides are enclosed by the property wall and home. The spacing between railings is no more than 4 inches. The distance between the ground and the bottom of the fence is less than and 1/2 inch from the hard surface (concrete). Licensee was advised the mesh fencing must be compliant with the American Society for Testing and Materials (ASTM) International Standard F2286. The mesh fencing is sturdy and capable of withstanding the impact of children's toys including bicycles and does not readily bend upon Impact. Per licensee the mesh fencing was damaged due to the recent winds which made it detach from the homes wall. Licensee agrees that the fencing will remain in place whenever licensed care is provided, and so long as the mesh fence makes the swimming pool inaccessible to the children. A life ring with a minimum exterior diameter of 17 inches with a United States Coast Guard approval label was not observed. A rescue pole with a body hook and a minimum fixed length of 12 feet was not observed.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 197414408
VISIT DATE: 01/27/2025
NARRATIVE
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 Licensees was advised that before opening the facility, a daily inspection of the drowning prevention safety features and safety equipment must be performed and maintain a log of the inspections to be provided to the department upon request. LPA did not observe the daily inspection log. There are no other bodies of water on the premises. LPA took photos to document in the file. For more information see the following website: https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1596.814&lawCode=HSC

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunizations Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunization's against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. Licensee’s pediatric CPR/First Aid was completed on 8/16/23. Mandated Reporter Training Completed on 1/18/24.

On this date, 3/27/07 the California Attorney General - Megan's Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

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.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 197414408
VISIT DATE: 01/27/2025
NARRATIVE
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 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.

LPA discussed the safe sleep regulations with licensee 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.

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/.

Licensee was 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 Sylvia Hernandez confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Based on LPA's observations, a Type A deficiency, listed on the attached LIC809D (deficiency page), is being cited in accordance with Title 22, Division 12, Chapter 3, of the California Code of Regulations. Deficiencies that are being cited need to be cleared to protect the children's health & safety.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6
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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 197414408
VISIT DATE: 01/27/2025
NARRATIVE
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LPA Jeanine Lipsey informed licensee 1/27/25 that this report dated 1/27/25 documents.
One Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, Safety, or personal rights of children in care.

Also, LPA Jeanine Lipsey informed the licensee to provide a copy of this licensing report dated 1/27/25 that documents any Type A citation to parents/guardian 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 (LIC9924), or written statement, must be placed in the child's file for verification.

The following items need to be corrected by 2/26/25.
1. The mesh fencing is not attached to the wall to prevent a child from entering.
2. The pool door does not self-lock or close.
3. Must have a pool cover or alarm.
4. Must have a 17' US Coast Guard life ring.
5. Must have a 12 foot rescue pole with body hook.
6. Daily inspection of drowning prevention safety features.

All items must have documentation from the American Society for Testing and Materials (ASTM) international standards.

Exit interview conducted and report was reviewed with the Licensee Sylvia Hernandez. A notice of site visit was given and advised Licensee that it must remain posted for 30 days.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
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