197416481-10-2-2024-12-CC-MRIA-D9NVTJ-20241002164314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197416481
Report Date: 10/02/2024
Date Signed: 10/02/2024 04:44:54 PM

Document Has Been Signed on 10/02/2024 04:44 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	SHIRLEY FAMILY CHILD CARE		FACILITY NUMBER:	197416481
ADMINISTRATOR/ DIRECTOR:	SHIRLEY, KIMBERLY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 904-7211
CITY:	SAUGUS	STATE: CA	ZIP CODE:	91350
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 11	DATE:	10/02/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:05 PM
MET WITH:	Jasmine Barila, Assistant		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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On Wednesday, October 2, 2024, at 2:05 p.m., Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with assistant Jasmine Barila who granted access and guided LPA Rivera on a tour of the facility.

Family members residing in the home have been discussed with assistant and are cleared. LPA observed 3 infants (12-23 months) and 8 preschool children present. LPA observed facility to be within ratio and present staff are fingerprinted cleared and trained in pediatric first aid/CPR. Operating hours are Monday to Friday from 7:00 a.m. to 5:00 p.m. and care for children ages 0 to 5 years old.

This facility is a two-story home that consists of 4 bedrooms, 3 bathrooms, kitchen, living room, dining room, laundry room, and front and backyard.

Areas off limits to children include- All second floor (barricaded with installed safety gate), bedroom, and bathroom (in bedroom) located first floor near the entrance hallway, kitchen, laundry room, and pool area.

Areas accessible to children include- living room, dining room, bathroom located in the hallway and backyard.

LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Rivera observed central AC/heater and the vents located on the ceiling. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA observed a fireplace and observed a childproof lock on the screen. Per assistant, the fireplace has not been turned on and is off and requires a key to turn on. LPA did not observe play yard or cribs. LPA observe the sleeping mats to be in good condition.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 10/02/2024

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LPA Rivera observed cleaning compounds items and knives sharp objects stored in the laundry room. LPA observed the door closed and locked with a key. For water drinking, LPA observed water filtered and sippy cups. The assistant stated the facility provides snacks and meals. LPA informed assistant any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. Assistant stated currently does not have any children with severe food allergies and has two children with prescribed Albuterol. LPA observed both Albuterol with expiration dates 11/2025 and 2/2025 and LIC 9221 Parent Consent for Administration of Medications.

LPA Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA did not observe hazard materials and observed the bathroom to be in good condition. LPA reminded assistant and personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Rivera asked the assistant if there were any pets, poisons, firearms, weapons, or bodies of water. The assistant stated one dog and a turtle, poisons, and body of water. No firearms, and no weapons. LPA observed one dog, poisons in the laundry room, and in- ground pool in the backyard. LPA observed the pool area to have a mesh fence and does not cover all around and the bottom of the fence has no gap openings. To complete the full coverage, LPA observed a brick wall that is shared with side and back neighbors. There are no windows on the side of the brick walls (pool area). LPA measured the height of the mesh fence from the ground up to the top of the fence to be 5.0 ft high and fence does not obscure the pool from view. The openings of the railings, LPA measured and observed the openings to be 3 inches wide. LPA observed the door to swing away from the pool and the self-latching device is no more than 6 inches from the top of the gate. LPA reminded assistant, the mesh fencing must not be removed and no ladders or any climbing equipment near the fencing. LPA informed assistant, if in the future the fencing needs to be replaced, licensee will need to contact the department to notify about the change.

LPA observed the poisons to be stored in the laundry room and the doorknob is locked. LPA reminded that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition/firing pins must be stored separately.

LPA Rivera observed the required 2A10BC fire extinguisher located in the dining room and the valve on the

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 10/02/2024

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green area indicating fully charged. LPA observed purchased receipt dated 11/20/2023. LPA observed carbon monoxide detector in the laundry room and smoke alarm located in the hallway. LPA tested the carbon monoxide and smoke alarm. LPA Rivera heard the sounds and are operable. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic wipes and located in the daycare room top cabinet. For ill isolation, assistant stated she utilizes a corner of the daycare room. LPA observed the last emergency drill conducted on 8/6/24.

LPA Rivera inspected the play outdoor (backyard) area that is utilized by children for safety, comfort, and cleanliness. LPA observed the backyard to be fenced and side gates closed and with a self-latch. LPA observed the play equipment to be age appropriate and in a safe condition, free of sharp, no lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA recommended to place a mesh cover on the AC compressor. For outdoor water drinking, children bring out their water bottles.

LPA Rivera observed assistant Jasmine American Heart Association Pediatric First Aid/ CPR dated 8/1/23. and has proof of immunization against Pertussis, MMR, and Influenza declination. Assistant has completed the Child Abuse Mandated Reporter training dated 11/12/23.

LPA observed the postings License, LIC 9148 Earthquake Preparedness Checklist, LIC 610A Emergency Disaster Plan, and Pub 394 Notification of Parents Rights. LPA also reviewed safe sleep logs, children’s roster, children, and staff files.

The following was also discussed with the assistant:

1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 10/02/2024

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3. Licensee was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

4. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

5. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

6. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated

7. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

8. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

9. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

10. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

11. Smoking is prohibited in the family childcare home.

12. Children and staff records must be maintained and updated as needed and be available for review by the Department.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 10/02/2024

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13. Immunization Requirement: H&S 1597.622: 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. The licensee and all adults working with children have proof of immunizations.

14. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

15. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

16. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

17. Liability Insurance was discussed; LPA advised licensee to review Title 22 Regulation 102417(m)(1) for additional information.

18. Dog(s) and/or pets are recommended to be isolated from children in care.

19. No, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.

20. LIC 126 Checklist for Family Child Care provided and reviewed.

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.

Assistant Jasmine 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

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 10/02/2024

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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 assistant Jasmine 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 assistant Jasmine 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.

LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.

Assistant Jasmine 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.

Assistant Jasmine, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

No deficiencies given during this visit. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted, and report was reviewed with the assistant Jasmine Barila.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

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