197495118-9-16-2022-30-CC-JLAO-CJBN7L-20220916101253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197495118
Report Date: 09/15/2022
Date Signed: 09/16/2022 10:13:18 AM

Document Has Been Signed on 09/16/2022 10:13 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:	OLGUIN FAMILY CHILD CARE		FACILITY NUMBER:	197495118
ADMINISTRATOR:	ADA OLGUIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(424) 268-4670
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	09/15/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Ada Olguin		TIME COMPLETED:	11:30 AM

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On 09/15/2022 Licensing Program Analyst (LPA) Judy Laureano conducted an announced inspection with applicant Ada Olguin for the purpose of an inspection of 3007 Urban Avenue, Santa Monica, CA 90404. Inspection was conducted in Spanish. The purpose of this inspection is to ensure the standards for a Family Child Care Home are being met in accordance to California Tittle 22 Regulations and California Health and Safety Codes.

The licensee is applying for a Large Family Child Care Home license for a max capacity of 14. This application is a change of location- facility #197412364 located on 4126 McLauglin Avenue, Los Angeles, CA 90066. Per the application, at this time, the ages the applicant wishes to provide services for are children 1 month old to 12 1/2 years old with the hours of Monday through Friday from 8:00 a.m. to 5:00 p.m. Licensee 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.

The applicant is currently renting/leasing the home, proof of control of property was provided and Landlord Consent form was filed. Currently living in the home is applicant and husband Jose Roberto Olguin.

The home is a single family unit with 3 bedrooms with 2 bathroom, living room, dining room, kitchen, laundry and detached garage space.

Parents will access the home through the main entrance. Entering the home, you are led to the area where the sign in sheet and facility sketch were observed. The living room was observed with a barricaded fire place. Children size cubbies were observed in the space. Applicant confirmed families will come in and check in their children. The living room area is OFF LIMITS to the children in care. A safety gate was observed making the living room inaccessible.

The dinning room was observed with children’s size tables and chairs and a 2 high chairs. Licensee confirmed children will eat in the space.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: OLGUIN FAMILY CHILD CARE	FACILITY NUMBER: 197495118
	VISIT DATE: 09/15/2022

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Next to the dining room area designated as child care space you are led to Bedroom 2/play room. Applicant stated children will nap in the space and the space has been designated for younger children. LPA observed a carbon monoxide and smoke detector in the space. Two cribs were observed in the space and applicant is available for infant care.

Next to bedroom 2/play room you are led to a hallway that leads to bathroom 1 and bedroom 1/office. Both areas have been designated as OFF LIMITS to the children in care. Doors will remain locked during the hours of operations.

LPA observed licensee test the carbon monoxide and smoke detector in the area. All electrical outlets were observed to be covered.

The kitchen area was observed and will be used as a walkway to access the outdoor space.The kitchen area was observed and inspected. Cabinets were observed to have safety latches. Knife and sharp objects are stored in the top drawer, making it inaccessible to the children in care.

Licensee confirmed that facility will be providing meals and snacks. LPA discuss food preparation, storage and ensuring a log and information regarding dietary restrictions and allergies are kept up to date. Licensee stated she will be participating in the local food program.

Outside the kitchen, an space was observed to have a changing table. The area was observed to have a closet with a safety latch. Working Fire extinguisher was observed in the space. The space has a door that leads to the outdoor space.

The laundry room was observed. Both washer and dryer unit were observed to have a safety latch. The space will be used as a walkway to access the bathroom that children will use. Bathroom 2 was observed and inspected. All electrical outlets were covered. Bathroom was observed to have a door with a doorknob cover on that leads to bedroom 3/play room.

Bedroom 3/ play room was observed outside the laundry room. All electrical outlets were covered. LPA observed age appropriate toys. LPA observed built in cabinets that were inspected. Applicant confirmed that extra day care materials are stored in the space. LPA observed napping cots in the cabinets and the space will be use for nap time.

The outdoor space was observed. Children size plastic slide and other age appropriate materials were observed in the space. A green house was observed next to an added extra activity space. LPA observed an extra space that with age appropriate toys and books.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: OLGUIN FAMILY CHILD CARE	FACILITY NUMBER: 197495118
	VISIT DATE: 09/15/2022

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Licensee stated she will use the space for added activity space only.

LPA discussed the LIC 311D and provided applicant with a packet of LIC forms.

The following areas are OFF LIMITS to the children in care:

1. Bedroom 1/office, bathroom 1- doors will remain locked during hours of operations.
2. Detached garage- door will remain locked during hours of operations.

No corrections were needed during today’s inspections. Exit interview was conducted with licensee Ada Olguin.

The following was discussed with the applicant: Applicant was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on childcare licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541 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.

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

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: OLGUIN FAMILY CHILD CARE	FACILITY NUMBER: 197495118
	VISIT DATE: 09/15/2022

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CHILDREN'S FORMS/RECORDS
Children's files must contain the following documents/information:
• Parent Notification, Additional Children in Care (LIC 9150), if you plan to care for more than 6 children for a Small Family Child Care Home, or more than 12 for a Large Family Child Care Home.
• Copy of document verifying child’s enrollment in Kindergarten or K-T. (22 CCR 102421(c)) • Affidavit Regarding Liability Insurance (LIC 282) - This form is required to be signed by each parent of a child in care if you do not have either liability insurance or a bond.
• Consent for Medical Treatment (LIC 627) - This document gives you permission by the parent to seek emergency medical or dental care for their child if needed.
• Consent/Verification for Nebulizer Care (LIC 9166) - Before a child care licensee or staff person can administer inhaled medication to a child in care, this form must be completed and filed in the child's record and in the personnel file. A separate form must be filled out for each person who administers inhaled medication to the child.
• Identification and Emergency Information (LIC 700) - This form must be kept for each child in care and identifies whom to call in an emergency.
• Notification of Parents' Rights (LIC 995A) - This form must be given to each parent at the time a child is accepted for care, along with the LIC 995E.
• Caregiver Background Check Process (LIC 995E) - This form must be given to each parent at the time a child is accepted for care, along with the LIC 995A.
• Family Child Care Consumer Awareness Information (LIC 9212) - This form must be given to the parents of each child in care.
• California School Immunization Record (PM 286) or Confirmation of required immunization for children not enrolled in a public or private elementary school - For every infant, toddler, or preschool age child admitted into a Family Child Care Home, the provider must maintain current immunization records. PM 286 can be downloaded from the following website: http://www.cdph.ca.gov NOTE: Personal beliefs statement no longer applies (2015 SB 277).
• Acknowledgement of Receipt of Licensing Reports (LIC 9224), if applicable.
• Blood Glucose Testing Consent (LIC 9222) Must be signed by parent prior to administering test.
• Individual Infant Sleeping Plan (LIC 9227) – Must be kept for infants up to 12 months of age.
• Sleep Logs – must be kept for infants up to 24 months of age.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: OLGUIN FAMILY CHILD CARE	FACILITY NUMBER: 197495118
	VISIT DATE: 09/15/2022

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FACILITY FORMS/RECORDS
• Facility files must contain the following documents/information:
• Personnel Records as required in Title 22, Division 12, Chapter 3, Section 102416.1, including but not limited to, proof of current pediatric first aid, CPR and preventive health practices certificate, lead poisoning training, mandated reporter training (2015 AB 1207), TB test results, measles, pertussis and influenza/may decline influenza, and documentation of either a criminal record clearance or a criminal record exemption.
• Unusual Incident/Injury Report (LIC 624B) - You must use this form and submit it to your local licensing office when reporting any incidents or injuries occurring during day care hours.
• Child Care Facility Roster (LIC 9040) - It is required that each child care facility maintain a current roster of children who are provided care.
• Notice of Employee Rights (LIC 9052) - This form must be filled out by all employees working in the Family Child Care Home.
• Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108) -This form is the Child Care Custodian's acknowledgement of the requirement to report suspected child abuse.
• Property Owner/Landlord Consent Form (LIC 9149), if you plan to care for more than 6 children for a Small Family Child Care Home or more than 12 for a Large Family Child Care Home.
• Property Owner/Landlord Notification Form (LIC 9151).
• Proof of control of property, including but not limited to a copy of your deed, mortgage statement or property tax bill, or lease/rental agreement.
• Verification that fire drills and disaster drills are conducted every six months.
• Emergency Disaster Plan (LIC 610A) - Evidence satisfactory to the department that there is a fire escape and disaster plan for the facility and that fire drills and disaster drills will be conducted at least once every six months.
• Earthquake Preparedness Checklist (LIC 9148) or equivalent, must be attached to the LIC 610A and available to the public.
INFORMATION TO BE POSTED IN YOUR FAMILY CHILD CARE HOME
You are required by law to post the following in your home:
• Facility Sketch (LIC 999A) or equivalent sketch
• Notification of Parents' Rights Poster (PUB 394) - This poster must be placed in an area of the home where all parents can see it.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: OLGUIN FAMILY CHILD CARE	FACILITY NUMBER: 197495118
	VISIT DATE: 09/15/2022

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• Facility License (LIC 203)-Your Family Child Care Home License must be posted in an area of the home where it can be easily seen.
• Notice of Site Visit (LIC 9213) must remain posted for 30 days (during the hours that children are in care) after each site visit by a licensing representative.
• Any licensing report documenting a type “A” citation must be posted for 30 days during the hours that children are in care.
• Any licensing report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

Licensee was made reminded that it is the licensee’s, as well as anyone who assists in providing care responsibility to know the regulations. Licensee was also encouraged to read the Child Care quarterly updates every season as they come out to stay informed of any changes or updates to statutes and regulations.
Applicant was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family childcare home during the hours of operation.

Applicant was made aware that state law prohibits baby walkers, bouncy seats, exer-saucers and any other items that fall into that category. Applicant was also reminded that only children who are eating may be in highchairs and that car seats are utilized only for transportation.
Applicant was also informed that the provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome.

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.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: OLGUIN FAMILY CHILD CARE	FACILITY NUMBER: 197495118
	VISIT DATE: 09/15/2022

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LPA also informed applicant 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.

Not providing: Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

Applicant was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides 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 Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed.

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 CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.
A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.

Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated. (If paying by check please make sure to write facility number on check to ensure that payment is applied to your facility number)
The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

Page: 6 of 8

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: OLGUIN FAMILY CHILD CARE	FACILITY NUMBER: 197495118
	VISIT DATE: 09/15/2022

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Changes should be reported the to the Department as soon as they occur such as construction and remodeling, telephone number changes and/or if you move from home.

Reporting requirements: Applicant must report any unusual incident or injuries to the Child Care Regional office by telephone within 24 hours and in writing within 7 days. Applicant was provided with LIC 624 as a reference.

Fire and safety drills must be performed every six months and documented for review by the Department.

All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov
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: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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