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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415718
Report Date: 06/17/2022
Date Signed: 06/17/2022 02:07:52 PM

Document Has Been Signed on 06/17/2022 02:07 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:ZAVALA FAMILY CHILD CAREFACILITY NUMBER:
197415718
ADMINISTRATOR:ZAVALA, LYDIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 299-8888
CITY:LOS ANGELESSTATE: CAZIP CODE:
90062
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 5DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lydia Zavala, LicenseeTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Alicia Mooberry conducted a Required Annual Inspection in English on this date. LPA met with Lydia Zavala, Licensee. LPA explained the purpose of the inspection and provided inspection Entrance Checklist, LIC 126. LPA inspected rooms/areas on the facility sketch in which child-care services are provided and to which children have access. Per licensee the hours of operation are Monday-Friday 6:00am-7:00pm. There were 5 children present. At 9:30am Elsy Velasquez, (Staff#1) arrived. File review revealed that Staff #1 has obtained a Criminal record clearance, but has not been associated the family Day Care, this poses a potential risk to the health of safety of children in care. Individuals living in the home were discussed and noted. Licensee confirmed that all individuals living in the home have obtained a Criminal record Clearance.
This is a single story unit in a duplex (east side). The home was inspected as follows: Living room, kitchen with dining area, 3 bedrooms, 1 bathroom, front yard and backyard.

Areas Accessible to children include: living room, dining area, kitchen, Bathroom, and front yard.


Off limit areas, per Licensee and facility sketch are: 3 bedrooms, back yard.

The bathroom that children use is located at the end of the hallway and observed to be clean and free of hazards.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:


The First Aid kit was observed by the front door inside of the emergency kit.

LPA observed required posted documentation in facility entrance which included: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA observed completed facility records including; LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan.


LPA provided licensee with PUB 394 with updated Regional Office information
-------Page 1 – Report Continues
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Alicia Mooberry
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: ZAVALA FAMILY CHILD CARE
FACILITY NUMBER: 197415718
VISIT DATE: 06/17/2022
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Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged and observed in box, Licensee was reminded that fire extinguisher needs to be serviced or purchased yearly and proof of purchase or service tag need to be available for inspection. The home maintains telephone service via cell phone - current phone number obtained. There are toys and other age appropriate material available for children. Licensee was reminded to use equipment such as car seats for their intended purpose and never to sleep in. Children should never be left in the vehicle unsupervised or unattended. LPA observed that licensee is implementing COVID-19 precautions and procedures.

LPA observed that detergents, cleaning compounds are in the storage in the hallway inaccessible to children. LPA discussed that poisons stored in the home must be locked, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in living room, away from the other children. Per Licensee there are no firearms or weapons stored in the home.

Infant Care: LPA informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP. Licensee states, should infants enroll, they will sleep in crib in living room and supervised for the duration of the nap and document 15 minute checks.

Currently, children are using the front yard for outdoor play. The outdoor play area was observed to be fenced. Licensees provided written plan of supervision due to the units on either side of the facility are accessible to children in care. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that could be hazardous to children in care. There are no bodies of water and no pets.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, and documentation of 15-minute Infant Sleep Check (0-24 months)

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 immunizations 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. Immunization records were missing for Child #1 and Child #2, and Staff #1 is missing MMR and TDAP, posing a potential risk to children in care.
-------------------Page 2 – Report Continues
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
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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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: ZAVALA FAMILY CHILD CARE
FACILITY NUMBER: 197415718
VISIT DATE: 06/17/2022
NARRATIVE
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LPA observed construction of an addition to the rear of the home. LPA observed that children in care do not have access to the construction. Licensee provide a plan of supervision for children in care to ensure their safety. Licensee was reminded to report any changes, including construction to Licensing within 24 hours.

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-and-resources/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 Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

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.

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.

Based on the LPA's observations and records review the following deficiencies will be cited today in accordance with California Title 22 Regulations.

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


Exit interview conducted and report was reviewed with the Licensee, Lydia Zavala. Appeal Rights were discussed and a copy provided
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/17/2022 02:07 PM - It Cannot Be Edited


Created By: Alicia Mooberry On 06/17/2022 at 12:27 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: ZAVALA FAMILY CHILD CARE
FACILITY NUMBER: 197415718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff files reviewed did not have the required Mandated Reporter Certificate which posesa potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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Per licensee, they will ensure that staff will complete the (Mandated Reporter mandatedreporterca.gov) training (General and AB1207) and email Certificate of completion to LPA by POC due date
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 review, the licensee did not comply with the section cited above in that Child #1 and #2 did not have immunization record on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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Per licensee, they will obtain immunization record and email copy to LPA by POC due date
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:Valarie Cook
LICENSING EVALUATOR NAME:Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/17/2022 02:07 PM - It Cannot Be Edited


Created By: Alicia Mooberry On 06/17/2022 at 12:27 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: ZAVALA FAMILY CHILD CARE
FACILITY NUMBER: 197415718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102370(d)(2)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 102370(j) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that Staff, Elsy Velasquez has not transered Trustlin clearance to child care facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2022
Plan of Correction
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LPA obtained, documentation required to transfer trustline clearance to the above Family Child Care home.
Type B
Section Cited
CCR
102416.3(a)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:

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 constuction in the backyard was not reported to licensing department which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2022
Plan of Correction
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Licensee provided a plan of supervising during construction. Licensee will provide a completed LIC 624 reporting the construction to the licensing department by email to MPSWIncidentReports@dss.ca.gov by the POC due date.
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:Valarie Cook
LICENSING EVALUATOR NAME:Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/17/2022 02:07 PM - It Cannot Be Edited


Created By: Alicia Mooberry On 06/17/2022 at 12:27 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: ZAVALA FAMILY CHILD CARE
FACILITY NUMBER: 197415718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above in that 1 out of 2 staff record revierwed did not have Measles and TDap proof of vaccination which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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Per licensee, proof of MMR and TDap vaccination for Staff, Elsy Velasquez will be sent to LPA email by 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:Valarie Cook
LICENSING EVALUATOR NAME:Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
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