197495019-6-8-2023-30-CC-ARIR-CSLMN9-20230608094510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197495019
Report Date: 06/08/2023
Date Signed: 06/08/2023 09:45:17 AM

Document Has Been Signed on 06/08/2023 09:45 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:	DOLBERRY FAMILY CHILD CARE		FACILITY NUMBER:	197495019
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 7	DATE:	06/08/2023
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Darryl Dolberry, Licensee		TIME COMPLETED:	10:00 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 06/08/2023, Licensing Program Analyst (LPA) Adrian Risher conducted an announced Case Management visit for the purpose of an inspection for a proposed capacity increase. LPA met with Darryl Dolberry, Licensee and toured the facility inside and out. The facility is applying for a capacity increase from 8 to 14. LPA observed 7 children in care with 1 assistant. Hours of operation are Monday through Friday from 4am to 12am . The fire clearance was granted on 05/23/2023 by inspector Ashlin Wilburn.

The single family home has 5 bedrooms and 2 bathrooms. The daycare will consist of the den. These areas were inspected by LPA. The other bedrooms and rooms are considered off-limits and inaccessible. Licensee owns the home.

The den is used for daily activities, eating and napping. The children use cots for napping. LPA observed age appropriate toys, furniture and activities for children while in care at the facility.

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 observe 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.

The children use the backyard as the outside play area and it is gated all around.

LPA observed a charged fire extinguisher (2-A:10-B:C). LPA tested the smoke detector and carbon monoxide detector. Licensee has a first aid kit which includes band aids and a thermometer. The home has central air and heat.

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Adrian Risher
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 06/08/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Applicant has current CPR, first aid, health and safety which expires 09/2023. Staff files were found to be current and complete.

There are no firearms on the premises. Licensee reports that there is 1 dog in the home.

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.

There are no corrections needed

A license to operate a Large Family child care home will be reviewed following final administrative review. No license will be issued today 06/08/2023.

Licensee 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 licensee 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 licensee 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

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 licensee Darryl Dolberry.

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Adrian Risher
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2