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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495019
Report Date: 03/14/2023
Date Signed: 03/14/2023 04:07:36 PM

Document Has Been Signed on 03/14/2023 04:07 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: 4DATE:
03/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Torrey Barnette, AssistantTIME COMPLETED:
04:30 PM
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On 3/14/2023, Licensing Program Analyst (LPA) Adrian Risher conducted an Annual Inspection. LPA provided Assistant with the purpose of the visit and was granted access to the facility. LPA met with Torrey Barnette, Assistant. LPA toured the inside and outside of the property with the Assistant. LPA observed the home to be clean, safe, orderly and well ventilated. There were 4 children present. The operating hours are Monday thru Friday 5am to 10pm

LPA observed the home to have a Living Room, Dining Room, Kitchen, 4 bedrooms, and 2 bathrooms. The Licensee utilizes the den as the day-care. The rest of the home is inaccessible to the children. The children do daily activities, eat and nap in the den. LPA observed cots that are used for napping.LPA observed age appropriate toys and equipment for the children.

The kitchen and bathroom areas were inspected for proper storage of chemicals, detergents, cleaning compounds, medications and sharp pointed objects. These items were made inaccessible to children.

Assistant states that there are no weapons in the home. Assitant reports that there is 1 small dog in the home. LPA observed operable smoke detectors and carbon monoxide detectors throughout the home. The home is equipped with 2 (2-A:10-B:C) Fire Extinguisher and First Aid kit which includes thermometer and band aids. The home has central air and heat.

LPA inspected the outside area and observed age appropriate toys. There are no bodies of water at the home. The outside play area is fenced all around.

Staff and children's files were reviewed during inspection. LPA reviewed records related to earthquake drills and fire drills which were found to be current. All required Child Care Postings was observed on the Parent Board during inspection.

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Adrian Risher
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: DOLBERRY FAMILY CHILD CARE
FACILITY NUMBER: 197495019
VISIT DATE: 03/14/2023
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No deficiencies were cited today.

Facility representative 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.

LPA discussed the safe sleep regulations with 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. LPA also informed 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.

LPA reviewed with facility representative 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.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the facility representative Torrey Barnette

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

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC809 (FAS) - (06/04)
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