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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418150
Report Date: 09/02/2021
Date Signed: 09/02/2021 12:25:09 PM

Document Has Been Signed on 09/02/2021 12:25 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: 0CENSUS: 6DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Adrianne Moore, LicenseeTIME COMPLETED:
12:35 PM
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Licensing Program Analysts (LPA's) Denise Gibbs and Steven Tung conducted an unannounced annual required inspection at the above facility on 9/2/21 at 9:30 AM. LPA's met with Adrianne Moore, Licensee who guided analysts on a tour of the facility. There were six children and four adults present when LPA's arrived.

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. Temporarily main care is provided in the living room. The children use the bathroom through the hallway adjacent to the main care area. Per Licensee, areas temporarily off limits to children and parents include: dinning room, one bedroom and back yard due to reorganizing and cleaning. Areas always off limits to children and parents are one bedroom (locked), kitchen, garage (locked), and back house (locked). Hours of operation are Mon-Fri 5am-11pm. Weekends are available by request.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption. Licensee states that there are no firearms or weapons stored in the home.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is operable telephone service at the facility via landline and cell phones. There is ventilation via fans and air conditioning/heat unit.

The following was observed and reviewed during this inspection:
LPA's observed that cleaning products are stored in the closet in the hallway on a high shelf, inaccessible to children. Poisons are stored in the off limits kitchen, locked under the sink. Isolation area for sick children waiting to be picked up is located in the bedroom/infant room away from the other children, supervised by staff.------------------Page 1
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: MOORE FAMILY CHILD CARE
FACILITY NUMBER: 197418150
VISIT DATE: 09/02/2021
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The valve on the required 2A 10BC fire extinguisher indicates fully charged and was last serviced on 7/2020 as noted on the service tag. Smoke and carbon monoxide detectors were tested and are operable.

The home is observed to be clean and orderly. There are toys and other age appropriate material available for children. Children nap on cots in main care living room. The bathroom that children use was observed to be clean and free of hazards.

Infant Care: Currently licensee does not care for children under two years old. LPA's did observe sleep plan and 15 minute check form for children who are no longer enrolled. LPA's discussed new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15 minute check documentation for infants 0-24 months, and provided PIN 20-24-CCP.

Children use the backyard for outdoor play. Per licensee back yard is temporarily off limits until 9/7/21 due to reorganizing and cleaning. The outdoor play area was observed to be fenced. LPA's observed that the outdoor yard has toys and other materials for children to play with. LPA's did observe play areas and material in the process of being reorganized. There are no pools or spas, or other bodies of water.



Per review four out of six Children’s records were not able to be reviewed for emergency information. Per licensee, due to the reorganization, the files are not available. Per licensee all staff have contact information for each child on her phone.

Staff Three (S3) does have proof of Pediatric CPR and first aid, expiration date 11/23/21. Per licensee, she and the other two staff (S1) and (S2) do have proof of CRP but it is with the misplaced files. At least one staff in the home does have Pediatric first aid and CPR. Licensee and S1 do have proof of immunization against influenza/declination, pertussis, and measles. S2 and S3 do not have all immunization available to be reviewed. Licensee and all staff could not provide renewed proof of Mandated Reporter, AB 1207 compliant Child Care Training.

LPA conducted COVID-19 Technical Assistance visit with licensee. LPA observed that licensee is still implementing COVID-19 precautions and procedures.

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

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: MOORE FAMILY CHILD CARE
FACILITY NUMBER: 197418150
VISIT DATE: 09/02/2021
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Incidental Medical Services (IMS):
The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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.


Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit made by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.



Exit interview was conducted with Adrienne Moore, Licensee, including, but not limited to Appeal Procedures and Appeal Rights.
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/02/2021 12:25 PM - It Cannot Be Edited


Created By: Denise Gibbs On 09/02/2021 at 11:23 AM
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: MOORE FAMILY CHILD CARE
FACILITY NUMBER: 197418150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited
HSC
1596.8662(4)(b)(1)

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1596.8662(4)(b)(1) Availability...proof of completion
(b) (1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider...shall complete the mandated reporter training...
This requirement was not met as evidenced by:
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Per licensee, all staff will renew their training and licensee will email the certificates to LPA by 9/7/21
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Based on interview and record review licensee did not provide proof of Mandated Reporter Training for herself, S1, S2 and S3.
This poses a potential Health, Safety or Personal Rights risk to children in care.
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Type B
10/01/2021
Section Cited
CCR102421(b)

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102421(b) The licensee shall maintain in each child's record, a copy of the emergency information card that contains all the information specified by the regulation.

This requirement was not met as evidenced by:
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Per licensee she will locate the files and email proof of LIC 700 to LPA by 9/7/21
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Based on interview and record review licensee did not provide emergency information for 4 out of 6 children.
This poses a potential Health, Safety or Personal Rights risk to children in care
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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:Trevino Cochran
LICENSING EVALUATOR NAME:Denise Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/02/2021 12:25 PM - It Cannot Be Edited


Created By: Denise Gibbs On 09/02/2021 at 11:28 AM
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: MOORE FAMILY CHILD CARE
FACILITY NUMBER: 197418150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited
HSC
1597.622(a)(1)

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1597.622 (a) (1) Employee and Volunteer Immunization 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.
This requirement was not met as evidenced by:
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Per licensee, she will get the immunization's records and email proof to LPA by 10/1/21.
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Based on interview and record review licensee did not provide proof of Immunization's against Measles, pertussis and Influenza or declination for S2 and Measles for S3.
This poses a potential Health, Safety or Personal Rights risk to children in care.
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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:Trevino Cochran
LICENSING EVALUATOR NAME:Denise Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
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