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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418938
Report Date: 12/06/2022
Date Signed: 12/06/2022 02:50:16 PM

Document Has Been Signed on 12/06/2022 02:50 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:CAVA FAMILY CHILD CAREFACILITY NUMBER:
197418938
ADMINISTRATOR:CAVA, ELAINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 477-7783
CITY:LOS ANGELESSTATE: CAZIP CODE:
90025
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Elaiine Cava- LicenseeTIME COMPLETED:
03:01 PM
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Licensing Program Analyst (LPA), Keyona Scott, conducted an unannounced Annual Required inspection to the Family Child Care Home on 12/06/2022. LPA arrived at facility at approximately 10:27 AM and met with Licensee at 10:56 AM. Present during today's inspection were Licensee, Assistant (A1), Licensee's spouse (A2) and six (6) children which includes four (4) infants. All Adults present in the home have a criminal record clearance or exemption.

PHYSICAL PLANT

All areas on the facility sketch were identified. This a one-story home with two bedrooms, two bathrooms, an office, kitchen, living room, dining room (converted into the childcare room), rec room and detached garage. Per Licensee, no childcare is conducted in the detached garage. The off-limit areas of the home are: the master bedroom and bathroom located at the rear of the home, the office located adjacent to the master bedroom, the rec room located adjacent to the dining room and the living room. The rec room and living room are made inaccessible by safety gates at dining room entrances. The master bedroom and office are inaccessible by closed door at hallway entrance to rear of home during operation hours. Hours of operation are Monday through Friday, 8:00 AM to 5:00 PM. The primary childcare area is in the dining room, which has been converted into a childcare area. Children nap in the dining room area. LPA observed napping mats available for the children in care. LPA also observed sleep and play yards stored in the isolation room. The bedroom located at the front of the home is utilized as an isolation area when children in care become ill. The bathroom directly through the hallway entrance is utilized by the children in care. LPA observed safety latches on bathroom cabinets. Children dine and snack in the kitchen. LPA observed safety latches on kitchen drawers and hazardous, poisonous and sharp objects inaccessible to children in care. Licensee provides two meals (breakfast and lunch) and two snacks (morning and afternoon) to children in care.
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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAVA FAMILY CHILD CARE
FACILITY NUMBER: 197418938
VISIT DATE: 12/06/2022
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Outdoor play is conducted in the enclosed driveway at the rear of the home. The outdoor play area is fully fenced in and free of hazards. LPA observed a children's table and bench sets, a playhouse and other age-appropriate toys in the outdoor play area. LPA advised Licensee that children in care are shall be supervised at all times.

The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children in care. The home has working telephone service and telephone number on file with the Department was confirmed and verified. All poisons, to include, detergents, cleaning compounds, medication and other hazardous materials are inaccessible to children in care. There is a fully charged fire extinguisher that is at least a 2A: 10BC in the home. There is at least one working carbon monoxide detector in the home. Centralized heat and air conditioning ventilation system is used as a heating and cooling source. LPA observed safe and age-appropriate toys and play equipment in the home.

According to Licensee, there are no weapons, firearms or ammunition on the premises; none were observed by LPA. Licensee was informed if obtains, firearms and ammunition must be stored and locked separately.

Per Licensee, there are no pets in the home; none were observed by LPA.

FACILITY RECORDS



LPA observed Licensee and Assistant's current Pediatric CPR and First Aid certificates with expiration dates of 09/22/2024. Licensee and Assistant renewed and completed Mandated Reporter training on 04/11/2022.

LPA reviewed the following Personnel Records for Licensee and/or Assistant:
  • Current Pediatric CPR and First Aid certification
  • LIC 9052 (Employee Rights)- Assistant
  • Proof of Immunization for MMR (Measels), Tdap (Pertussis) and Influenza or waiver- Licensee
  • TB clearance or risk assessment- Licensee
  • LIC 9108 (Statement Acknowledging Requirement to Report Child Abuse)
  • Mandated Reporter Training Certificates
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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAVA FAMILY CHILD CARE
FACILITY NUMBER: 197418938
VISIT DATE: 12/06/2022
NARRATIVE
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LPA provided Licensee and Assistant with the following Personnel Record to complete and place in each file:
  • LIC 508 (Criminal Record Statement and Out of State Disclosure)- During inspection, LPA observed Licensee and Assistant complete LIC 508 and was placed in each file.

LPA reviewed the following Children's Records for five (5) children present in care during inspection:
  • LIC 282 (Affidavit Regarding Liability Insurance)
  • Immunization Record
  • LIC 700 (Identification and Emergency Information)
  • LIC 627 (Consent for Emergency Medical Treatment)
  • LIC 995A (Notification of Parents' Rights)

LPA observed the following required documents posted:
  • Facility License
  • PUB 394 (Notification of Parents' Rights)- LPA provided Licensee with updated form with current Regional Office name, address and telephone number

LPA provided Licensee with the following required postings to post on parent board:
  • PUB 394- Notification of Parents' Rights (Updated Copy)
  • LIC 9148- Earthquake Preparedness Checklist

LPA reviewed the following documents during today's inspection:
  • LIC 610A (Emergency Disaster Plan)
  • Verification of Disaster and Fire Drills- Per LPA review, disaster and fire drills are conducted monthly by Licensee; LPA observed last disaster and fire drill last conducted on 11/13/2022.
  • LIC 9040 (Facility Roster)

LPA identified the following locations during the inspection:
  • Medication stored at the facility- Per Licensee, no children currently require medication and no medication is currently stored at facility.
  • Functioning Carbon Monoxide Detector, Smoke Alarm, and Fire Extinguisher- LPA observed fire extinguisher was last serviced in March 2022.
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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAVA FAMILY CHILD CARE
FACILITY NUMBER: 197418938
VISIT DATE: 12/06/2022
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The following was thoroughly discussed with Licensee:
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 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.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

The facility was operating in substantial compliance during today’s inspection on 12/06/2022. Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

Exit interview conducted and report was reviewed with the licensee, Elaine Cava.


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
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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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