197494934-2-2-2022-30-CC-DWHE-CB9REW-20220202115813

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494934
Report Date: 02/02/2022
Date Signed: 02/02/2022 11:58:35 AM

Document Has Been Signed on 02/02/2022 11:58 AM - 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:	MOSS FAMILY CHILD CARE		FACILITY NUMBER:	197494934
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	02/02/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Debra Moss		TIME COMPLETED:	12:05 PM

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On February 2, 2022 Licensing Program Analyst (LPA) Doris Whitmore and Licensing Program Manager (LPM), Karren Starks conducted an announced inspection with applicant Debra Moss, for the purpose of a pre-licensing inspection of 10404 Crenshaw Blvd. #1 Inglewood CA 90303. The purpose of this inspection 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 applicant is applying for a Large family childcare license with a max capacity of 14. Property owner/landlord consent (LIC 9151) is currently on file. The license is currently the only living in the home. Lease agreement/control of property was received.

Per the application, currently the ages the applicant wishes to provide services for children 0 to 13 years old with the hours of operation of 24 hours a day Monday- through Sunday. Applicant will be available for overnight care. Applicant were informed that any changes to ages, hours, days of operation shall be submitted to the department for approval prior to initiation of changes. The location is gated, but an access code nor key is required. The courtyard area to the home is gated, the applicant stated that the parents can contact her for entry upon arrival and in the future the applicant will obtain and install a Ring doorbell for entry.

The home is a 3 bd, 2 ba. first story apartment with living room, kitchen and laundry room. The living room was observed to have a large aquarium with fish.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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: MOSS FAMILY CHILD CARE	FACILITY NUMBER: 197494934
	VISIT DATE: 02/02/2022

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The children will not have access to the fish. There was a fireplace observed that was not properly barricaded and an extension surge cord that must have outlet covers inserted. There were age appropriate furniture and toys observed. A heating duct door was observed to be accessible, must be barricaded to prevent entry. The home has central heating and air conditioning.

The kitchen was observed to have a gate to prevent access to the area. The cabinet beneath the sink was observed to have cleaning supplies. Also the drawers need safety latches to prevent access. The dining room area was observed to have furniture and chairs, the television in this area had accessible wiring which needs to be made inaccessible. The three doors on the right side of the hallway are to be made inaccessible with child safety knobs, one of which is the water heater. The laundry room was observed, there is a large cabinet that housed the laundry detergent, applicant must make this cabinet inaccessible. The 2A10BC Fire extinguisher was observed in the kitchen and fully charged First Aid Kit was observed.

There is an entry door in the laundry area that the applicant wishes to use for daily entry of children. A parent board was observed in this area with the required postings being given to the applicant. The two rear bedrooms will be used for child care. Bedroom #1, next to laundry room was observed to have an operable carbon monoxide detector with age appropriate toys. The chairs were observed to be too large for toddlers to use. The changing pad was observed and did not have a safety lip to prevent a child from falling. The cubby area was observed to have blankets which the applicant was advised regarding the items touching. Also outlets in this room need to have child safety covers inserted.

Rooms #2 was observed to have an operable carbon monoxide detector and age appropriate furniture and toys. The outlet covers in this room must have proper coverings.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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: MOSS FAMILY CHILD CARE	FACILITY NUMBER: 197494934
	VISIT DATE: 02/02/2022

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Room #3 was observed to be the applicant’s bedroom, there were no items observed to be a risk to children in care and will remained locked during child care hours when children are in care.

The bathroom for children in care which is just outside of the applicant’s bedroom was observed and did not have any toxins, medications or chemicals that would pose a risk to children in care.

Per the applicant there are no other adults or children living in the home. There are no weapons in the home, LPA/LPM did not observe any weapons at the time of inspection.

For outdoor activity the applicant stated that she will take the children to Darby Park. The applicant was advised that she is to ensure the children are property supervised and the parents are made aware that this is the place that will be used. The applicant has an enclosed courtyard area, but does not wish to use it for outdoor activity space at this time. No bodies of water were observed.

The FCCH will not provide Incidental Medical Services (IMS) policy was discussed.

· Applicant was reminded that all adults and over 18 living and 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 the regulation is violated

· 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

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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: MOSS FAMILY CHILD CARE	FACILITY NUMBER: 197494934
	VISIT DATE: 02/02/2022

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CPR& Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.

· A current roster of children enrolled must be maintained and available

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

· Reporting requirements: Applicant must report any unusual incidents or injuries to the Child Care Regional Office by telephone within 24 hours and in writing within 7 days

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

Mandatory Forms for the children’s files and provider’s files were discussed. Applicant was referred to LIC311D: FORMS TO BE POSTED

LIC203 Facility License
LIC 610A Emergency Disaster Plan
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
LIC 9166 Consent/Verification for Nebulizer Care
CDPH 286 (Immunization Blue Card) with Immunization record

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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: MOSS FAMILY CHILD CARE	FACILITY NUMBER: 197494934
	VISIT DATE: 02/02/2022

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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
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.

Forms/ Records to Keep in your Family Child Care Home

Prior to licensure the following will need to be corrected:

Barricade the fireplace

Barricade the heating air duct

Secure the cabinet beneath the sink and the drawers

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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: MOSS FAMILY CHILD CARE	FACILITY NUMBER: 197494934
	VISIT DATE: 02/02/2022

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Cover the television cords in the dining area

In the laundry room, secure the cabinets to make them inaccessible

All electrical outlets in the child care areas must be covered

Safety knobs must be placed on the closet/water heater doors in the hallway

The following was discussed:

Assembly Bill (AB) 633: Upon receipt by the licensee, licensees are to provide to parents/guardians the following: Copies of any licensing reports that document a Type A citation- this includes facility visits and substantiated complaint investigations; copy of licensing documents pertaining to a conference conducted by a local licensing agency management representative and the licensee of this family child care home in which issues of noncompliance are discussed or copies of a summary of an accusation indicating the Department's intent to revoke the facility's license. Copies of any of the above licensing documents the licensee has received in the prior 12 months shall be provided to parents/guardians of newly enrolled child at the facility.
Criminal Record Clearance. All adults who reside or work in the home must obtain a criminal record clearance or exemption.
Mandated Reporter: Applicant was made aware of AB 1207, commencing January 1, 2018, 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 Health & Safety Code 1596.8662.
Shaken Baby Syndrome Awareness & Safe Sleep. Applicant was reminded never shake a baby to prevent Shaken Baby Syndrome. LPA discussed Safe Sleep Regulations with Applicant: 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; no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. 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 is completed and in file for each infant up to 12 months of age. Infants up to

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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: MOSS FAMILY CHILD CARE	FACILITY NUMBER: 197494934
	VISIT DATE: 02/02/2022

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12 months of age are placed on their backs for sleeping. Applicant was also reminded that only children eating may be in high chairs and that car seats are utilized only for transportation.
Incidental Medical Services Awareness. Incidental Medical Services (IMS) policy was discussed. Facilities that provide Incidental Medical Services (IMS) must identify those services in their facility’s Plan of Operation and submit an updated Plan of Operation to the Department. 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.

An exit interview was conducted, the applicant will have until 02/09/2022 to submit all corrections needed.

A copy of this report was provided.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

LIC809 (FAS) - (06/04)

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