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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700166
Report Date: 03/29/2022
Date Signed: 03/29/2022 11:39:40 AM

Document Has Been Signed on 03/29/2022 11:39 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:HENRY FAMILY CHILD CAREFACILITY NUMBER:
197700166
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
03/29/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elorine HenryTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) King-Lewis conducted an unannounced case management inspection for the purpose of conducting a capacity increase to a large family childcare. Licensee Elorine Henry is requesting to care for 14 children when a qualified assistant is present. LPA provide licensee with the large family ratio visual guide and the documents and training required for an assistant. Licensee is aware that all employees or volunteer 18 years of age or older shall be live scan cleared and immunized against pertussis, measles and maybe immunized against influenza; show proof of negative TB result and when left alone shall have current 1St aid and CPR training.

Currently residing in the home is the licensee, licensee spouse, licensee 16 years of age son upstairs bedroom #1, adult daughter bedroom 4, licensee is also a Certified Parent through Fred Jefferson Foster Family Agency license # 197806903, Licensee is approved to care for 5 placement children; licensee is currently caring for 5 placement children(10, 8, 5, 4, and 1 years of age)

Licensee guided analyst on a tour of the license day-care. Licensee states her daycare is open 24 hours and the day care take place in the following areas of the
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HENRY FAMILY CHILD CARE
FACILITY NUMBER: 197700166
VISIT DATE: 03/29/2022
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home: downstairs family room, 1 bathroom, dining area, back yard, upstairs bedroom #2 and #3, upstairs bathroom and the loft. Licensee has stair gate at the top and bottom of the stairs.

There are no body of water on the premises. Licensee has a small dog with current vaccination dated 03-09-21. LPA informed licensee prior to allowing children to play in back yard all dog feces shall be cleaned up. Licensee stated there are no firearms or other dangerous weapons. Storage areas for poisons, detergents, cleaning compounds and other items which could pose a danger to children are inaccessible to children kept in laundry room. Medication are stored in licensee bedroom secured with a key locked. Fire extinguishers, smoke detectors, and carbon monoxide were inspected and operable. There is a landline telephone and a cell phone available.

LPA discussed safe sleep regulation, making licensee aware no infant shall be swaddle and car seat shall not be used for sleeping, to supervise infants while they are sleeping by physically checking every 15 minutes and documenting the child status. Licensee was informed all infants shall have an individual infant Sleeping Plan (LIC 9227). Licensee should refer to regulation 102425(J) for documentation requirement. LPA informed licensee that infant shall sleep on the same level care and supervision is being provided. LPA provided 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: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HENRY FAMILY CHILD CARE
FACILITY NUMBER: 197700166
VISIT DATE: 03/29/2022
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Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in writing within 7 day of incident on the form LIC624B per the regulation.
Licensee states she provides transportation. LPA informed licensee to make sure the transportation vehicle is proper insured to transport day care children. Licensee reminded to keep facility roster of children, and fire and disaster drill current.

During this inspection facility was observed to be following Title 22 regulations.

Exit interview conducted, the report was reviewed. A copy of this report, Notice of Site Visit and Appeal Rights were provided.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
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