197494582-10-27-2022-58-CC-JLAO-CJYP7H-20221007110354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494582
Report Date: 09/19/2022
Date Signed: 10/27/2022 12:58:02 PM

Document Has Been Signed on 10/27/2022 12:58 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:	AMZALEG FAMILY CHILD CARE		FACILITY NUMBER:	197494582
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 6	DATE:	09/19/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Moran Amzaleg		TIME COMPLETED:	01:00 PM

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On 09/19/2022 Licensing Program Analyst (LPA) Judy Laureano conducted an announced inspection with Licensee Moran Amzaleg for the purpose of an inspection of 9225 Alcott Street, Los Angeles, CA 90035. The purpose of this inspection 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.

The licensee is applying for a Large Family Child Care Home license for a max capacity of 14. Per the application, at this time, the ages the applicant wishes to provide services for are children 18 months to 5 years old with the hours of Monday through Friday from 8:00 am to 4:00 pm. Licensee 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 licensee is currently renting/leasing the home, proof of control of property was provided with Landlord Consent was provided. Currently living in the home is licensee and husband Guy Man and 5 minor children. During the inspection, a census was taken, 6 children and one assistant were observed. Licensee’s husband was also present during part of the inspection. The home is a single-family home with 4 bedroom, and office, entry way, living room, 4 bathroom and powder room, dining room, breakfast area, kitchen and den/play room. Current facility sketch reviewed and licensee confirmed the following areas ALL OFF LIMITS: Front yard, entry way, living room, office, kitchen, breakfast area and guest bedroom and bathroom in the first floor, all of the second floor that include, 3 bedrooms and two bathrooms and patio and baseman. LPA observed a child safety mesh gate making the second floor inaccessible to the children in care.

Amend report per Fire Clearance approved on 10/4/2022 by Inspector H. Wood to reflect:Play room/Garage is not permitted to be use for day care at any time by children or staff.The pool needs to be remain fenced in and covered at all times. Basement not to be used at any time by children or staff.

Families will enter the facility through the side door of the home that leds you are led to the outdoor space. The back yard was observed and inspected. Age appropriate outdoor toys were observed. Children’s plastic outdoor toys and tricycles were observed. LPA observed in the middle of the back yard a non-functioning pool that has

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: AMZALEG FAMILY CHILD CARE	FACILITY NUMBER: 197494582
	VISIT DATE: 09/19/2022

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been filled and covered. LPA observed the cover sustain the weight of licensee’s husband. The area has also been made inaccessible to the children in care with a 5 foot gate.

The outdoor area is covered with artificial turf and offers a shady area with an outdoor sink. LPA observed an extra space at the end of the yard that has been designated as an extra playroom. The extra playroom was observed to have a closet that is kept locked that leads to a storage area. LPA observed the space and reminded licensee the space should only be used as additional activity space.

The outdoor area also was observed to have a enclosed space for 3 chickens , 2 turtles and a rabbit.

The outdoor space can be accessed through the sliding door in the breakfast room and the door in the den/play room. The den/play room was observed and inspected. LPA observed a current working fire extinguisher and fire pull station in the room. The den/ play room was observed to have children size tables and chairs, variety of manipulatives and children’s books. LPA observed children’s napping cots and children’s cubbies in the space. LPA observed the First Aid Kit and all necessary posting the in space. Licensee confirmed children will nap and eat the in the den/play room. LPA observed all electrical outlets covered. Licensee tested the carbon monoxide and smoke detector in the space.

Next to the den/play room you are led to the dining room. The dinning room was inspected and will be used as a walk way to access the bathroom.

The bathroom that children will use in located in the first floor next to the office. The bathroom was inspected and observed, LPA observed a powder room before entering the bathroom. LPA observed a toilet and sink. LPA discussed COVID 19 precautions and observed a hand washing sign and paper towels in the bathroom space.

Across the bathroom, the baseman door was observed to have a door knob cover. The baseman was inspected and designated as OFF LIMITS to the children in care. The entry way was observed and inspected. A closet that is used as a pantry was observed and made inaccessible to the children in care by the use of a plastic door knob cover. The Office was inspected and observed to have a plastic door knob cover.

The living room was inspected and off limits to the children in care. A fireplace was observed and licensee confirmed the fireplace is not used and a metal mesh gate was observed. Fire place is not connected.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: AMZALEG FAMILY CHILD CARE	FACILITY NUMBER: 197494582
	VISIT DATE: 09/19/2022

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Across the dining room you are led to the kitchen. The kitchen area was observed and inspected. Cabinets were observed to have safety latches where knives and sharp objects are stored. Medicine and vitamins were observed stored in the top latch cabinet making the content inaccessible to the children in care. Next to the kitchen you are led to a pantry like area were a second stove was observed and a second Fire Extinguisher. LPA observed a second exit that leads the side of the home that is OFF LIMITS to the children in care.

Next to the kitchen a breakfast area was observed and inspected. LPA observed a hockey table that is OFF LIMITS to the children in care. The breakfast area was observed to have a sliding room door that leads to the back yard.

Next to the breakfast area, the guest room and bathroom was observed to have a door knob cover making the guest bedroom and bathroom inaccessible to the children in care.

The bottom on the staircase was observed to have a safety gate making the 2^nd floor inaccessible. The second floor was inspected. Three bedrooms and two bathrooms were observed. Bedroom 1 gives access to a patio. Licensee confirmed all doors will remain locked during hours of operations.

Licensee confirmed that facility will be providing meals and snacks. LPA discuss food preparation, storage and ensuring a log and information regarding dietary restrictions and allergies are kept up to date. At

The following areas are OFF LIMITS to the children in care: entry way, office, living room, baseman, kitchen, breakfast area and guest room with bathroom. The 2^nd floor that includes: 3 bedrooms, 2 bathroom and the patio are all OFF LIMITS.

No corrections were needed during today’s inspections. Fire clearance is pending. Exit interview was conducted with licensee Moran Amzaleg.

The licensing determination of this application will be reviewed with Licensing Program Manager for final resolution.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: AMZALEG FAMILY CHILD CARE	FACILITY NUMBER: 197494582
	VISIT DATE: 09/19/2022

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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.

LPA reviewed with License the LIC 311D, Forms/Records To Keep In Your Family Child Care Home, children’s forms/records, family forms/records, and information to be posted.
CHILDREN'S FORMS/RECORDS
Children's files must contain the following documents/information:
• Parent Notification, Additional Children in Care (LIC 9150), if you plan to care for more than 6 children for a Small Family Child Care Home, or more than 12 for a Large Family Child Care Home.
• Copy of document verifying child’s enrollment in Kindergarten or K-T. (22 CCR 102421(c))
• Affidavit Regarding Liability Insurance (LIC 282) - This form is required to be signed by each parent of a child in care if you do not have either liability insurance or a bond.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: AMZALEG FAMILY CHILD CARE	FACILITY NUMBER: 197494582
	VISIT DATE: 09/19/2022

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• Consent for Medical Treatment (LIC 627) - This document gives you permission by the parent to seek emergency medical or dental care for their child if needed.
• Consent/Verification for Nebulizer Care (LIC 9166) - Before a child care licensee or staff person can administer inhaled medication to a child in care, this form must be completed and filed in the child's record and in the personnel file. A separate form must be filled out for each person who administers inhaled medication to the child.
• Identification and Emergency Information (LIC 700) - This form must be kept for each child in care and identifies whom to call in an emergency.
• Notification of Parents' Rights (LIC 995A) - This form must be given to each parent at the time a child is accepted for care, along with the LIC 995E.
• Caregiver Background Check Process (LIC 995E) - This form must be given to each parent at the time a child is accepted for care, along with the LIC 995A.
• Family Child Care Consumer Awareness Information (LIC 9212) - This form must be given to the parents of each child in care.
• California School Immunization Record (PM 286) or Confirmation of required immunization for children not enrolled in a public or private elementary school - For every infant, toddler, or preschool age child admitted into a Family Child Care Home, the provider must maintain current immunization records. PM 286 can be downloaded from the following website: http://www.cdph.ca.gov NOTE: Personal beliefs statement no longer applies (2015 SB 277).
• Acknowledgement of Receipt of Licensing Reports (LIC 9224), if applicable.
• Blood Glucose Testing Consent (LIC 9222) Must be signed by parent prior to administering test.
• Individual Infant Sleeping Plan (LIC 9227) – Must be kept for infants up to 12 months of age.
• Sleep Logs – must be kept for infants up to 24 months of age.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: AMZALEG FAMILY CHILD CARE	FACILITY NUMBER: 197494582
	VISIT DATE: 09/19/2022

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FACILITY FORMS/RECORDS
• Facility files must contain the following documents/information:
• Personnel Records as required in Title 22, Division 12, Chapter 3, Section 102416.1, including but not limited to, proof of current pediatric first aid, CPR and preventive health practices certificate, lead poisoning training, mandated reporter training (2015 AB 1207), TB test results, measles, pertussis and influenza/may decline influenza, and documentation of either a criminal record clearance or a criminal record exemption.
• Unusual Incident/Injury Report (LIC 624B) - You must use this form and submit it to your local licensing office when reporting any incidents or injuries occurring during day care hours.
• Child Care Facility Roster (LIC 9040) - It is required that each child care facility maintain a current roster of children who are provided care.
• Notice of Employee Rights (LIC 9052) - This form must be filled out by all employees working in the Family Child Care Home.
• Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108) -This form is the Child Care Custodian's acknowledgement of the requirement to report suspected child abuse.
• Property Owner/Landlord Consent Form (LIC 9149), if you plan to care for more than 6 children for a Small Family Child Care Home or more than 12 for a Large Family Child Care Home.
• Property Owner/Landlord Notification Form (LIC 9151).
• Proof of control of property, including but not limited to a copy of your deed, mortgage statement or property tax bill, or lease/rental agreement.
• Verification that fire drills and disaster drills are conducted every six months.
• Emergency Disaster Plan (LIC 610A) - Evidence satisfactory to the department that there is a fire escape and disaster plan for the facility and that fire drills and disaster drills will be conducted at least once every six months.
• Earthquake Preparedness Checklist (LIC 9148) or equivalent, must be attached to the LIC 610A and available to the public.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: AMZALEG FAMILY CHILD CARE	FACILITY NUMBER: 197494582
	VISIT DATE: 09/19/2022

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INFORMATION TO BE POSTED IN YOUR FAMILY CHILD CARE HOME
You are required by law to post the following in your home:
• Facility Sketch (LIC 999A) or equivalent sketch
• Notification of Parents' Rights Poster (PUB 394) - This poster must be placed in an area of the home where all parents can see it.
• Facility License (LIC 203)-Your Family Child Care Home License must be posted in an area of the home where it can be easily seen.
• Notice of Site Visit (LIC 9213) must remain posted for 30 days (during the hours that children are in care) after each site visit by a licensing representative.
• Any licensing report documenting a type “A” citation must be posted for 30 days during the hours that children are in care.
• Any licensing report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

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.

Applicant was made aware that state law prohibits baby walkers, bouncy seats, exer-saucers and any other items that fall into that category. Applicant was also reminded that only children who are eating may be in highchairs and that car seats are utilized only for transportation.
Applicant was also informed that the provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome.

LPA discussed the safe sleep regulations with applicant [or facility representative] 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.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: AMZALEG FAMILY CHILD CARE	FACILITY NUMBER: 197494582
	VISIT DATE: 09/19/2022

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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 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

Licensee was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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 Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed.

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.
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

LIC809 (FAS) - (06/04)

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