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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493367
Report Date: 07/22/2024
Date Signed: 07/22/2024 03:41:33 PM

Document Has Been Signed on 07/22/2024 03:41 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:BENAVIDES FAMILY CHILD CAREFACILITY NUMBER:
197493367
ADMINISTRATOR/
DIRECTOR:		BENAVIDES, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 201-7091
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 14TOTAL ENROLLED CHILDREN: 5CENSUS: 7DATE:
07/22/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Ana Benavides, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Silva Garibyan conducted a site visit for the purpose of an unannounced Required-3 Year visit. LPA met with the licensee and toured the home inside and outside at 12:00 PM on 07/22/2024. There were seven children ( including one infant and one school age child) present at the time of the visit. The children's roster was reviewed and is current. Per licensee, the facility’s hours of operation are 8:30AM - 4:30 PM, Monday - Friday. All areas identified on the facility sketch were inspected. Licensee's home is a single story, 4 bedroom, 2 bathroom home with a living/dining room, kitchen, and detached converted garage. The living/dining room, kitchen, the two bedrooms in the hallway, the bathroom in the master bedroom, and the detached garage are off limits to the children in care. There is no pool, spa or other bodies of water on the premises. The main entry door is not used to enter the facility. Parents and children use the side door leading to the bedroom/play room. The children have access to the bathroom in the hallway. There are age appropriate toys and equipment for the children. The LPA toured all areas used by children during this inspection. The bathroom and the kitchen was observed free of chemicals or toxic items that can pose danger to children in care.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: BENAVIDES FAMILY CHILD CARE
FACILITY NUMBER: 197493367
VISIT DATE: 07/22/2024
NARRATIVE
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The outdoor play area was inspected. Children's outdoor play equipment and toys are age appropriate and in good repair. LPA observed the yard to be fully fenced. Individuals residing in the home and in the converted garage have been discussed and noted. All adults present in the home/detached garage have obtained a criminal record clearance or exemption. The Fire Extinguisher (2A-10-BC) is mounted on the wall in the play room. There is a working smoke/carbon monoxide detectors located in the play room. The First Aid kit was observed, and complete. LPA observed the fire drill log. The fire drills are done every six months. Children utilize the side yard. The back yard is off limits to the children in care. LPA observed tables, chairs and napping equipment (including a crib and 7 cots). Licensee reports she has no firearms or weapons in the home. LPA observed Licensee's current Pediatric CPR (Adult/Infant /Child) and Pediatric First Aid certifications (expire 06/2025). Licensee did not have proof of completion of the Mandated Reporter AB1207 training.
Licensees provide meals and snacks. LPA discussed food preparation, storage and ensuring a log and information regarding dietary restrictions and allergies are kept up to date. Licensees stated that a cell phone with active service in the home will be the main contact number while children are in care.
A review of the children's records was conducted and are found to have the following: LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC702, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization Card. There was no documentation or log available by the Licensee for the time of each 15 minute check for the infant in care. LIC9227 was missing in the infant's file. Page 2
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: BENAVIDES FAMILY CHILD CARE
FACILITY NUMBER: 197493367
VISIT DATE: 07/22/2024
NARRATIVE
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LPA observed in the play room/bedroom the Parent Board with all necessary posting required ( Facility License (LIC 203), Emergency Disaster Plan (LIC610A), Notification of Parents' Rights Poster (PUB 394), If You see Something Say Something poster.
A review of records indicates that licensee does not have immunization records on file for influenza, pertussis and measles. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

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.



Licensee 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 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.
Licensee 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. Page 3
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: BENAVIDES FAMILY CHILD CARE
FACILITY NUMBER: 197493367
VISIT DATE: 07/22/2024
NARRATIVE
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One infant is enrolled at this time. LPA discussed the safe sleep regulations with licensees 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.
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.


During the exit interview, the licensee Ana Benavides informed that there are no Registered Sex Offenders living in the facility.

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

Exit interview conducted and report was reviewed with the licensee Ana Benavides.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2024 03:41 PM - It Cannot Be Edited


Created By: Silva Garibyan On 07/22/2024 at 01:47 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: BENAVIDES FAMILY CHILD CARE
FACILITY NUMBER: 197493367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensees did not comply with the section cited above in the licensees do not have a current Mandated Reporter Training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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LIcensee will complete Mandated Reporter training and email the verification certificate of completion on or before the end of business day on 7/24/2024. LPA provided the trainining website address. www.mandatedreportercom.ca
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Licensee does not have current Immunization's records ( againts influenza, pertussis, and measles) availabel for review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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Licensee will email a copy of Licensee's immunizations records by 07/29/2024.
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:Betty Bell
LICENSING EVALUATOR NAME:Silva Garibyan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/22/2024 03:41 PM - It Cannot Be Edited


Created By: Silva Garibyan On 07/22/2024 at 01:47 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: BENAVIDES FAMILY CHILD CARE
FACILITY NUMBER: 197493367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, and observation, the licensee did not have the completed LIC9227 in the infant's file during inspection. The licensee was not aware of the infant safe sleep regulations, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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Licensee will email the LIC9227 by 07/29/2024 for current infant enrolled that is under 12 months.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. There was no documentation or log available by the Licensee for the time of each 15 minute check for the infant, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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Licensee will generate a log for the infant enrolled and document the time of each 15 minute check and provide a copy of the log to CCL by the POC due date.
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:Betty Bell
LICENSING EVALUATOR NAME:Silva Garibyan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
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