<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494200
Report Date: 07/21/2021
Date Signed: 07/21/2021 01:16:22 PM

Document Has Been Signed on 07/21/2021 01:16 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:SEVAREID FAMILY CHILD CAREFACILITY NUMBER:
197494200
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/21/21 Licensing Program Analyst (LPA) Antonio Almanza, conducted an unannounced Annual Required Inspection and was met by Licensee MATTHEW SEVAREID, also present are his wife and 6 year old child. Days and hours of operation are Monday-Friday 8:30 am to 4:00 pm.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that living room and bathroom located next to kitchen are for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of child safety gate. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The fireplace located in the living room is made inaccessible by a wooden cover that has been inserted into the fireplace opening that serves as a book shelf and will not be in use during daycare hours.

There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is 818-970-8442.

There are currently no infants in care. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Pg 1.

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2021
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SEVAREID FAMILY CHILD CARE
FACILITY NUMBER: 197494200
VISIT DATE: 07/21/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan (LIC9227) is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were incomplete with 2 0f 4 files missing emergency information as required. Licensee’s was licensed on 07/30/2020 and Mandated Reporter Training should be current and on file but licensee is unable to provide a copy of certification. Licensee’s pediatric CPR/First Aid expires on 08/02/22. A review of records indicates that all employees and/or volunteers 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.


Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

pg 2.
SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SEVAREID FAMILY CHILD CARE
FACILITY NUMBER: 197494200
VISIT DATE: 07/21/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiencies are being cited: Tpe B violation fro childrens being incomplete and Technical Violation due to Licensee not being able to provide copy of Mandated Reporter Training Certificate after being licensed on 07/30/2021 (see next page, LIC809D and LIC9102) Licensee was provided a copy of appeal rights.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

Pg 3.

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/21/2021 01:16 PM - It Cannot Be Edited


Created By: Antonio Almanza On 07/21/2021 at 12:03 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: SEVAREID FAMILY CHILD CARE
FACILITY NUMBER: 197494200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2021
Section Cited
CCR
102421(b)

1
2
3
4
5
6
7
102421 Child's Records (b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7).

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will have LIC 700 completed by parents and provide copies to LPA by 07/23/21. Licensee agrees to maintain children’s files complete for all children in care and newly enrolled children.
8
9
10
11
12
13
14
Based on observation, interview and record review, The Licensee did not receive Emergency information for 2 of 4 children in care, which poses a potential Health or Safety, or personal rights risk to persons in care.
This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Type B
07/23/2021
Section Cited
CCR102418(g)

1
2
3
4
5
6
7
102418 Immunizations (g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
1
2
3
4
5
6
7
Licensee will receive a copy of childrens immunizations records from parents and provide copies to LPA by 07/23/21. Licensee agrees to maintain children’s files complete for all children in care and newly enrolled children.
8
9
10
11
12
13
14
Based on observation, interview and record review, The Licensee did not receive immunization records for 2 of 4 children in care, which poses a potential Health or Safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
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:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2021


LIC809 (FAS) - (06/04)
Page: 4 of 4