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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494882
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:12:06 PM

Document Has Been Signed on 01/12/2023 01:12 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:PEPPER FAMILY CHILDCAREFACILITY NUMBER:
197494882
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
01/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Natally Pepper, LicenseeTIME COMPLETED:
01:22 PM
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On 01/12/2023 Licensing Program Analyst (LPA) Shandra Powell conducted an announced inspection with Natally Pepper, Licensee for the purpose of an increase of capacity inspection for the facility located above. The purpose of this increase of capacity visit is to ensure the standards for a Family Child Care Home are being met in accordance to California Title 22 Regulations and California Health and Safety Codes.
The licensee is applying for an increase of capacity; Large Family Child Care Home license for a maximum capacity of 14. A fire clearance was approved by LA County Fire Department on 12/01/2022. Facility was licensed for a Small (8) Family Child Care Home on 09/09/2021.

The applicant and spouse own the property. LPA received landlord consent form LIC9149 from spouse.

The capacity of increase requested by licensee is for a Large Family Child Care Home to provide for up to 14 children during business hours with an assistant. Per the application, currently ages the applicant wishes to provide services for are children 3 to 6 years old with the hours of operation of Monday- Friday from 9:00 AM to 2:00 PM. 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.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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: PEPPER FAMILY CHILDCARE
FACILITY NUMBER: 197494882
VISIT DATE: 01/12/2023
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This is a one-story home which consists of 3 bedrooms, 4 bathrooms, kitchen, dining room, living room, front yard and backyard (fenced) next to the backyard LPA observed and inspected a second home on the property, address is 5046 Willowcrest Avenue, North Hollywood 91601. LPA received a copy of the Certification of Occupancy dated 10/29/2020. Per licensee no one lives in the home and the space is now used for children to conduct activities during child care hours. The off limits areas of the home consist of kitchen, living room, dining room, 3 restrooms all located in the main home. Per licensee the front yard is not used for outdoor activities. The children use the bathroom located in day care room#1, LPA observed no hazards under cabinets. LPA observed a large glass shower with child lock on door making the shower inaccessible to children. Day care room #2 also has a bath room that is used by children in care, which is located in the second home on the property. Day care room #1 and #3 use central air and heating for a cooling and heating source. The backyard will be used by day care children for outdoor play and for snack and lunch.

LPA observed a large variety of age appropriate toys and learning materials inside of classrooms. The outdoor space was observed to have a variety of age appropriate activities with a large wooden swing set that sits on top of a material that absorbs a fall. The play area was inspected for hazards and inaccessibility to bodies of water. The second outdoor space has artificial turf for children to sit and play.

Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible. The applicant states that all poisons, medication and hazardous items are in the off limit areas inaccessible. The licensee does understand that poison must be locked with a key or combination lock. LPA observed one cat and licensee stated she does have one dog who was not home during inspection. Licensee stated the cat and dog are never around the children in care and are kept in the main home (off limit area) when children are in care

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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: PEPPER FAMILY CHILDCARE
FACILITY NUMBER: 197494882
VISIT DATE: 01/12/2023
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Licensee does not prepare meals for children. Licensee stated children bring their meals from home. LPA reminded licensee all lunch boxes, cups or any items brought into home must be labeled with children's names on them at all times. A fire extinguisher was observed in class room #1 and class room #3. First aid kit was observed. LPA observed a carbon monoxide and smoke detector located in class room #1.

Applicant stated no weapons, firearms, or bodies of water on the premises. Posting requirements were observed all postings were posted during inspection.



LPA observed the children’s file however file was not complete. LIC 995A was missing and or not completed during inspection. Licensee did not have a Disaster Drill log during inspection this poses a potential health and safety risk to children in care. LPA did not observe a copy of the Mandated Reporter Training certification for assistants during inspection. LPA advise licensee to have all employees complete the Mandated Reporter Training and place certifications in each employees file.

Licensee 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. LPA gave the licensee the Guardian.ca.gov web page to register her facility to make updates for facility and employees.

Applicant was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. Provides many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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: PEPPER FAMILY CHILDCARE
FACILITY NUMBER: 197494882
VISIT DATE: 01/12/2023
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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.

Capacity and Ratios: The licensee has applied for a capacity increase for a large family . The Maximum capacity is 12 with no more than 4 infants and a qualified assistant. Without a qualified assistant the license reverts back to the requirements for a small family childcare. Optional care may be provided for a maximum capacity of 14 children with no more then 3 infants, 2 school age children and a qualified assistant. School age children must be 1 age 6 yrs and 1 in Kindergarten.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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: PEPPER FAMILY CHILDCARE
FACILITY NUMBER: 197494882
VISIT DATE: 01/12/2023
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FORMS TO BE POSTED
· LIC203 Facility License
· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster
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
· Immunization record
· PUB 72- Family Child Care Consumer Guide
· LIC 995A Notification of Parent’s Rights
· CDPH 286 (Immunization Blue Card)
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 610A Emergency Disaster Plan
· LIC 9151 Property Owner/Landlord Notification Form
· Proof of current pediatric CPR and First Aid Certificates and Mandated Reporter Certificates(renewed every two years)

At this time, the applicants home meet the description of a safe and healthy environment for children as described in Chapter 1, Division 12, Title 22 of the California Code of Regulations, and will be submitted for approval to be licensed as a Large Family Child Care Home.


The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit made by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with Licensee, and Appeal Procedures provided
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC809 (FAS) - (06/04)
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