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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494395
Report Date: 02/23/2022
Date Signed: 07/10/2023 12:17:59 PM

Document Has Been Signed on 07/10/2023 12:17 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:MACK FAMILY CHILD CAREFACILITY NUMBER:
197494395
ADMINISTRATOR:ADRIENNE MACKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 625-3211
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
02/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Adrienne MackTIME COMPLETED:
03:30 PM
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On 2/23/2022 at 2:00 PM Licensing Program Analyst (LPA) Judy Laureano conducted an announced case management inspection due to licensee's inactive period ending. Licensee has had an inactive status since 09/29/2021 through 02/14/2022. The purpose of this visit is to ensure the standards for a Family Child Care Home are being met in accordance to California Tittle 22 Regulations and California Health and Safety Codes.

Upon arrival LPA met with licensee Adrienne Mack, LPA did not observe children present. Licensee is licensed for a Large Family Child Care Home with a max capacity of 14. Licensee wishes to provide services for children ages 2 to 5 years old with the hours of operations being Monday through Friday from 6 pm to 11pm and Saturday and Sunday from 9 am to 1 pm and/or 3 pm to 11 pm depending on need. Applicant was informed that any changes to ages, hours and days of operation shall be submitted to the department for approval prior to initiation of changes.



The home is a two story, three-bedroom, two-bathroom house, living room, dining room, kitchen and a family room. The parents will enter from the side of the home. The family room/den and living room are designated as the childcare room. The home is clean, orderly, comfortable and well ventilated.

LPA observed a working smoke detector, carbon monoxide detector, charged 2A10BC fire extinguisher and working telephone. The home has central heating and air conditioning. All electrical outlets, detergents, cleaning supplies and medications are inaccessible to children.

The bedrooms, living room, dining room and kitchen are off limits and will remain inaccessible. LPA observed a latch for one bedroom which is used as an office. LPA
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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: MACK FAMILY CHILD CARE
FACILITY NUMBER: 197494395
VISIT DATE: 02/23/2022
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observed a doorknob cover for one bedroom and the bathroom. LPA observed the window blind cords child proofed. There is a child proof gate at the bottom of the stairs and at the entrance to the dining room. There is a latch on the washing machine/dryer room door located in the family room/den. LPA observed the First Aid kit stored in the kitchen. Fire extinguisher was observed to be mounted in the kitchen. Per the applicant, there are no firearms on the premises.

LPA inspected the outdoor patio which will be used as the children's outdoor play area. The patio is fenced and safe. The detached garage and backyard are off limits and the door will remain closed. There are no bodies of water. There is one small dog on the premises. The dog will be kept inaccessible from the children during hours of operations.

LPA confirmed the following documents:
1. Flu Waiver
2. COVID-19 Vaccination Record Card
3. Mandated Reporter Training for Child Care Providers taken 11/10/21
4. Preventative Health and Safety Training with LEAD and Nutrition taken 3/21/21
5. Pediatric First Aid, Child/Infant and Adult CPR AED expires 1/2023

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.


An exit interview was conducted with the licensee. A copy of this report was provided to the licensee and a notice of site visit.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
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: MACK FAMILY CHILD CARE
FACILITY NUMBER: 197494395
VISIT DATE: 02/23/2022
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The following was discussed with the applicant:
Applicant was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on childcare licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541
Email Address: childcareadvocatesprogram@dss.ca.gov

Immunizations: Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a childcare facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the inspection.

Mandated Reporter Training: Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. Website: www.mandatedreporterca.com. Licensee was reminded of their responsibility to report suspected child abuse.


Mandatory Forms for the children’s files and provider’s files were discussed. Applicant was referred to LIC 311D: Records To Keep in Your Family Child Care.

FORMS TO BE POSTED


LIC203 Facility License
LIC 610A Emergency Disaster Plan
LIC 9148 Earthquake Preparedness Checklist
PUB394 Notification of Parents Rights Poster
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
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: MACK FAMILY CHILD CARE
FACILITY NUMBER: 197494395
VISIT DATE: 02/23/2022
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Children’s Records Requirements:
LIC 700 Identification and Emergency Information
LIC 627 Consent for Emergency Medical Treatment
LIC 282 Affidavit Regarding Liability Insurance
LIC 9150 Parent Notification Additional Children in Care
LIC 9166 Consent/Verification for Nebulizer Care
CDPH 286 (Immunization Blue Card) with Immunization record
PUB 72- Family Child Care Consumer Guide
LIC 995A Notification of Parent’s Rights
LIC 995E Caregiver Background Check Process
LIC 9212 Family Child Care Consumer Awareness Information
LIC 9222 Blood Glucose Testing Consent
PM 286 California School Immunization Record (blue card)-http://www.dhs.ca.gov/publications/forms/immunization.htm
LIC 9224 Acknowledgement of Receipt of Licensing Report, if applicable.
Facility Records:
LIC 624B Unusual Incident/Injury Report
LIC 9040 Child Care Facility Roster
LIC 9052 Employee Rights,
LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
LIC 9149 Landlord Consent Form, if you plan to care for more than 6 for Small or 12 for Large
LIC 9151 Property Owner/Landlord Notification Form
Personnel Records as required in Tittle 22, Division 12, Chapter 3, Section 102416.1, including but not limited to proof of current pediatric CPR and First Aid Certificates, Preventative Health certificate and criminal record information.
Copy of your deed or lease/rental agreement
Documentation of Fire and Disaster drill
Proof of immunization's against pertussis (TDAP), measles (MMR), and influenza
Mandated Reporter certificate – www.mandated reporterca.com – renewed every two years.

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
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: MACK FAMILY CHILD CARE
FACILITY NUMBER: 197494395
VISIT DATE: 02/23/2022
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Licensee was made reminded that it is the licensee’s, as well as anyone who assists in providing care responsibility to know the regulations. Licensee was also encouraged to read the Child Care quarterly updates every season as they come out to stay informed of any changes or updates to statutes and regulations.

Applicant was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family childcare home during the hours of operation.



LPA also informed applicant [facility representative] 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.

This facility plans to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

Not providing: 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

· Applicant 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.

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
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: MACK FAMILY CHILD CARE
FACILITY NUMBER: 197494395
VISIT DATE: 02/23/2022
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· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license. · A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.

· Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated. (If paying by check please make sure to write facility number on check to ensure that payment is applied to your facility number)

· The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced.

· Changes should be reported the to the Department as soon as they occur such as construction and remodeling, telephone number changes and/or if you move from home.

· Reporting requirements: Applicant must report any unusual incident or injuries to the Child Care Regional office by telephone within 24 hours and in writing within 7 days. Applicant was provided with LIC 624 as a reference.

· Fire and safety drills must be performed every six months and documented for review by the Department.

· All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

· LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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