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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418150
Report Date: 07/29/2022
Date Signed: 07/29/2022 05:28:34 PM

Document Has Been Signed on 07/29/2022 05:28 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:MOORE FAMILY CHILD CAREFACILITY NUMBER:
197418150
ADMINISTRATOR:MOORE, ADRIENNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 240-5655
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Adrianne Moore, LicenseeTIME COMPLETED:
05:35 PM
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Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 7/29/22 at 3:15 PM. LPA met with Adrianne Moore, Licensee who guided analysts on a tour of the facility. There were 11 children and one assistant and two other adults present when LPA arrived. Facility capacity is in compliance for a large Family Child Care Home.

This is a one-story home which consists of two bedrooms, one bathrooms, kitchen, dining room, living room, front yard and backyard (fenced) and detached back house. Main care is provided in the living room and dinning room. The children use the bathroom through the hallway adjacent to the main care area. Per Licensee, areas off limits to children and parents include: two bedrooms, front yard, back yard, detached garage (locked), and blockhouse (locked).

Hours of operation are Mon-Fri 5AM-12:15AM. Weekends are available by request. Licensee provides food for the children. Licensee was reminded if children bring food from home it must be labeled with the child’s name and properly stored or refrigerated.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption.

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:

LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on 7/23/22. --------------------PAGE 1.
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: MOORE FAMILY CHILD CARE
FACILITY NUMBER: 197418150
VISIT DATE: 07/29/2022
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Smoke and carbon monoxide detector were tested and are operable. LPA observed required 2A10BC fire extinguisher, last serviced 4/2022. The home maintains telephone service via landline and cell phone. The home is observed to be clean and orderly. There age appropriate equipment, toys and material available for children. LPA observed that detergents, cleaning compounds, knives and medication are stored in the off limits kitchen and a locked storage in the hallway closet, inaccessible to children. Isolation area for sick children waiting to be picked up is in one of the off limit room or close off the living room or dining room, away from the other children. Per Licensee there are no firearms or weapons stored in the home.

The bathroom that children use was observed to be clean and free of hazards.

Infant Care: Currently licensee does not care for infants. LPA discussed 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.

Overnight Care: Licensee stated the following for overnight care supervision: Currently there are two children who are cared for late night. Children have sleeping equipment for overnight. Staff remain awake until children are picked up. Licensee is aware that they must remain awake while children are awake. If children sleep in separate area from licensee, the door must remain open. If licensee cannot hear children when they wake up, video or audio device can be used.

Currently, children are not playing outdoors. Per licensee, she is cleaning and reorganizing the outdoor area. Licensee will call LPA when she is ready to open the outdoor area for inspection. There are no pools or spas, or other bodies of water. Facility does have four small dogs that are kept in an off limits area during the day.



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

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC 508- Criminal Record Statement, Proof of immunization 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. Documents were discussed.
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SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: MOORE FAMILY CHILD CARE
FACILITY NUMBER: 197418150
VISIT DATE: 07/29/2022
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During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

LPA observed that licensee is implementing COVID-19 precautions and procedures.

Incidental Medical Services (IMS):
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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Based on the LPA's observations and records review no deficiencies will be cited today 7/29/22.

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/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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an

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SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: MOORE FAMILY CHILD CARE
FACILITY NUMBER: 197418150
VISIT DATE: 07/29/2022
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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.

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

Exit interview conducted and report was reviewed with the Licensee, Adrianne Moore.

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4