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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419477
Report Date: 03/17/2022
Date Signed: 03/17/2022 02:27:02 PM

Document Has Been Signed on 03/17/2022 02:27 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:SZELOG FAMILY CHILD CAREFACILITY NUMBER:
197419477
ADMINISTRATOR:SZELOG, LAUREN A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 494-1027
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Lauren SzelogTIME COMPLETED:
03:45 PM
NARRATIVE
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On March 17, 2022 at 12:14 PM, Licensing Program Analysts (LPA) Dean Thompson conducted an unannounced Annual/Random Inspection. LPA met with licensee Lauren Szelog and informed the licensee the reason for the inspection. Covid pre-screening questions were asked to make sure no one inside the home has tested positive for covid or have any flu like symptoms. Licensee gave LPA a tour inside and outside of the home. During the time of inspection there were 10 children in care and three adults.

LPA observed state licensing documents mounted on the wall downstairs inside the play room. LPA reminded licensee, state licensing documents are to be posted in a prominent, publicly accessible area at the facility.

Licensee uses downstairs play room, one bathroom, and backyard for the day care. All cabinets and drawers inside the day care area were closed and locked so that children do not have access. There were no toxins or hazardous material accessible to children in care. Licensee advised there are no firearms or ammunition in the home.

During the inspection, LPA reviewed children files, all files are current. Licensee advised there were no children in care that required Incidental Medical Services. Children have access to toys that are age-appropriate inside and outside the home. Outside play area has a framed enclosure. There are no bodies of water on the property.

Continued on 809-C
SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2022
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SZELOG FAMILY CHILD CARE
FACILITY NUMBER: 197419477
VISIT DATE: 03/17/2022
NARRATIVE
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Fire and earthquake drills are not being logged every six months. Licensee shall document the drills, including date and time of each drill. LPA viewed a 2A10BC fire extinguisher that was purchased 11/2/2017. Licensee was reminded, the home shall contain a fire extinguisher that is purchase or service once a year.
Licensee CPR/First aid certification expired 10/6/2021.

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.

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

Three Type B deficiencies were cited during today's inspection.

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.

Exit interview conducted and report was reviewed with the Lauren Szelog.

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
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Document Has Been Signed on 03/17/2022 02:27 PM - It Cannot Be Edited


Created By: Dean Thompson On 03/17/2022 at 01:42 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SZELOG FAMILY CHILD CARE
FACILITY NUMBER: 197419477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for family child care home. Licensee failed to purchase or service a 2A10BC fire extinguisher once a year which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2022
Plan of Correction
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Provide Proof of purchase or service date by March 31,2022 via email or text to LPA D. Thompson.
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:George Mingle
LICENSING EVALUATOR NAME:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


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Document Has Been Signed on 03/17/2022 02:27 PM - It Cannot Be Edited


Created By: Dean Thompson On 03/17/2022 at 01:42 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SZELOG FAMILY CHILD CARE
FACILITY NUMBER: 197419477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above. Licensee failed to maintain a fire/disaster drill log at least once every six months. Failure to document or conduct the drills poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2022
Plan of Correction
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Provide LPA Thompson documentation showing fire and disaster drills are being conducted every six months by plan of correction due date via email or text.

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:George Mingle
LICENSING EVALUATOR NAME:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/17/2022 02:27 PM - It Cannot Be Edited


Created By: Dean Thompson On 03/17/2022 at 01:42 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SZELOG FAMILY CHILD CARE
FACILITY NUMBER: 197419477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Licensee and assistant CPR/First Aid certification both had an expiration date of 10/6/2021, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2022
Plan of Correction
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Provide LPA Thompson proof of CPR/First Aid certification by plan of correction due date via email or text. CPR/First Aid certification must show pediatric.
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:George Mingle
LICENSING EVALUATOR NAME:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


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