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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495019
Report Date: 03/03/2022
Date Signed: 03/03/2022 02:29:20 PM

Document Has Been Signed on 03/03/2022 02:29 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:DOLBERRY FAMILY CHILD CAREFACILITY NUMBER:
197495019
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/03/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Darryl Dolberry ApplicantTIME COMPLETED:
02:45 PM
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On 3/3/2022, Licensing Program Analyst (LPA), Adrian Risher conducted a pre-licensing inspection for a family child care home. LPA met with applicant Darryl Dolberry at 1:04pm and toured the facility. Torrey Barnette(current licensee) and 1 assistant was present at the home during the inspection. LPA observed 7 children in care under Barnette FCC. The home is clean, orderly and comfortable. The adults in the home have been fingerprinted and associated to the facility. The hours of operation will be 5:00am to 10:00pm Monday thru Sunday. Applicant is requesting to have a family child care home with a capacity of 8.

The single family home has 4 bedrooms and 2 bathrooms. The daycare will consist of the den which is located in the back of the home. These areas were inspected by LPA. The other bedrooms and rooms are considered off-limits and inaccessible. Applicant owns the home. The parents will enter the home from the back entrance. LPA observed cots that will be used for napping. LPA inspected the bathroom and did not observe any medications or poisons that could pose a potential risk to children in care. The kitchen was inspected during the visit. LPA did not observed any knives or sharp objects, detergents or cleaning supplies that would pose a potential risk to children in care. These items were made inaccessible to the children with a baby gate at the entrance of the hallway. Applicant will use a cot and place it in front of the hallway door in the daycare room for isolating ill children. LPA observed age appropriate toys, furniture and activities for children while in care at the facility.

The outside play area is gated all around. LPA observed play houses and apparatuses in the outside play area. LPA did not observe any bodies of water.

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Adrian Risher
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
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: DOLBERRY FAMILY CHILD CARE
FACILITY NUMBER: 197495019
VISIT DATE: 03/03/2022
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LPA observed a charged fire extinguisher (2-A:10-B:C). LPA tested the smoke detector and carbon monoxide detector. Applicant has a first aid kit which includes band aids and a thermometer. The home has central air and heat. Applicant has current CPR, first aid, health and safety which expires 09/2023. Per the applicant, there are no firearms on the premises. Applicant reports that there are rabbits in the home. LPA did not observe any baby walkers, exersaucers or bouncers. Applicant provided copies of immunization record and mandated reporter certificate.


The parent board will be posted for parents to view required information such as the license, parent's rights poster, personal rights, and emergency disaster plan. A copy of the children's roster will be kept accessible.


The following corrections were discussed with applicant in order for the home to be ready for conducting child care:

1. latch on drawer in kitchen 3. flu waiver
2. safety lock on cabinet in kitchen underneath the sink 4. lic508 for Brittaney Starks

A license to operate a Small Family child care home will be reviewed following final administrative review, and receipt of outstanding corrections needed. No license will be issued today 3/3/2022. Applicant will notify LPA when corrections have been made, and the Applicant has 30 days to complete corrections.

Applicant was reminded that all adults 18 and over living in the home, persons who provide 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 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: Adrian Risher
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
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: DOLBERRY FAMILY CHILD CARE
FACILITY NUMBER: 197495019
VISIT DATE: 03/03/2022
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LPA discussed the safe sleep regulations with applicant 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. LPA also informed [applicant, licensee, or 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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



Exit interview conducted and report was reviewed with the Applicant .

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted

Entrance Checklist was provided to the applicant.

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: Maureen Neal
LICENSING EVALUATOR NAME: Adrian Risher
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC809 (FAS) - (06/04)
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