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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494882
Report Date: 09/08/2021
Date Signed: 09/08/2021 12:03:47 PM

Document Has Been Signed on 09/08/2021 12:03 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:PEPPER FAMILY CHILDCAREFACILITY NUMBER:
197494882
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/08/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Natallly PepperTIME COMPLETED:
12:15 PM
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09/08/2021 at 9:23 am, Licensing Program Analyst (LPA) Antonio Almanza conducted an announced Prelicesning Inspection and met with the applicant Natally Pepper who guided LPA on a tour of the home. The applicant is applying for a Small Family Child Care License to operate Monday to Friday from 9:00 am to 2:00 pm and serve children ages 3-6 years of age. The single-story home is a 3-bedroom, 4 bathroom home. The home has central A/C and Heater.

The applicant states the main care will be provided in the day-room located in the back left corner of the home and bathroom located in the dayroom. There is an office located next to the dayroom that will also be used for children in care. There is fireplace in the living room that is off-limits to children in care. The off-limits areas of the home are as follows: kitchen, living room, dining room, 3 bedrooms and 3 bathroom located in the main home.. Applicant states parents will provide meals and snacks to children in care. Applicant will use a cell phone for the family child care home and was advised that the cell phone should remain in the home while children are in care. Parents will drop off their children through the alley. There is a wooden privacy fence with metal gate that will be kept locked during hours of operation.

There is a fully equipped 2A10BC fire extinguisher or larger located in the kitchen. The applicant places all sharp items / knifes and medications in kitchen cabinet. LPA observed first aid kit. LPA observed an operating Smoke detector in Day room. Cleaning supplies are kept in top kitchen cabinet. Applicant stated there are no weapons or firearms in the home and LPA did not observe any.

The backyard will be used by children in care. The backyard has trees that provide shade to children in care. There a large play structure with slide for children to play in with artificial turf underneath. There is a dog in the home and kept in the off-limits areas of the home. There is a second home on the property that is located in the back-left corner of the property and is accessed through the alley. The tenant of that dwelling have received criminal record clearance. Pg 1.
SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
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: PEPPER FAMILY CHILDCARE
FACILITY NUMBER: 197494882
VISIT DATE: 09/08/2021
NARRATIVE
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The following was discussed with the applicant:
-Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please advise your analyst of any person who will be visiting regularly or for longer than one week. -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.
-Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. The family day care home shall maintain documentation of the required immunization's 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. -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. -The fire extinguisher type 2A-10BC must be serviced annually. 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. -Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. -Fire and safety drills must be performed every six months and documented for review by the Department. -The smoking of tobacco in a private residence that is licensed as a family child care home shall be prohibited and in those areas of the family day care home where children are present.
- Children and Staff records must be maintained and updated as needed and must be available for review by the Department. -Saucer chairs, bouncers, walkers, or any similar items are prohibited. -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.
Pg 2.
SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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: PEPPER FAMILY CHILDCARE
FACILITY NUMBER: 197494882
VISIT DATE: 09/08/2021
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The applicant was informed 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 to disseminate information on the State’s licensing role, provide information to the public and parents on child care 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: childcareadvocatesprogram@dss.ca.gov

AB 1207: Beginning on January 1, 2018, this law 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

Safe Sleep Links:
AAP:https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials, PIN 20-24-CCP: Recently Approved Safe Sleep Regulations In Effect. PIN 20-24-CCP: Recently Approved Safe Sleep Regulations In Effect

Incidental Medical Services: 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 Incidental Medical Services Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering EpiPen Jr. and EpiPen or other Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Emptying an Ileostomy Bag.
Pg 3.
SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: PEPPER FAMILY CHILDCARE
FACILITY NUMBER: 197494882
VISIT DATE: 09/08/2021
NARRATIVE
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Applicant was emailed LIC311D and forms where explained:
Children’s Files must contain the following documentation:
LIC 9150 Parent Notification Additional Children in Care - LIC 282 Affidavit Regarding Liability Insurance - LIC 627 Consent for Emergency Medical Treatment - LIC 9166 Consent verification of Nebulizer Care - LIC 700 Identification and Emergency Information - LIC 995A Notification of Parent’s Rights - LIC 995E Caregiver Background Check Process - LIC 9212 Family Child Care Consumer Awareness Information - Immunization record - LIC 9224 Acknowledgement of Receipt of Licensing Reports
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 Property Owner/Landlord Consent Form, if you plan to care for more than 6 children for a Small Family Child Care Home (FCCH) or more than 12 for a Large FCCH - LIC 9151 Property Owner/Landlord Notification Form - Proof of current pediatric CPR and First Aid Certificates - Copy of your deed or lease/rental agreement - Documentation of Fire and Disaster drills - Proof of immunizations against pertussis (TDAP), measles (MMR), and influenza - Mandated Reporter certificate www.mandatedreporterca.com – must be conducted every two (2) years
Forms to be posted:
LIC 610A Emergency Disaster Plan - LIC 9148 Earthquake Preparedness Checklist - PUB 394 Notification of Parents Rights Poster - LIC 9148 Earthquake Preparedness Checklist - PUB 394 Notification of Parents Rights Poster - LIC 203 Facility License - LIC 9213 Notification of Site Visits - Any licensing reports documenting a Type “A” citation posted for 30 days during hours that children are in care - Any licensing report or other documentation verifying compliance or non-compliance with the department’s order to correct type “A” deficiency must be posted for 30 days .

The applicant was advised that, once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. The applicant was made aware that a licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment.

Pg 4.
SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: PEPPER FAMILY CHILDCARE
FACILITY NUMBER: 197494882
VISIT DATE: 09/08/2021
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The applicant was emailed a copy of the RAST (covid-19) email and TA was provided during the time of the visit. The information provided was reviewed and the self-assessment was explained.


he following is needed prior to approval for licensure.
1. Anchor play structure to the ground
2. Install C/O detector
3. Install outlet covers in daycare room
4. LPA to verify that all required documents are on file.

5. Licensure approval by Licensing Program Manager.

An Exit Interview was conducted, and a copy of this report was provided to the applicant.

Pg 5.

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

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC809 (FAS) - (06/04)
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