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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700166
Report Date: 07/26/2022
Date Signed: 08/02/2022 04:54:48 PM

Document Has Been Signed on 08/02/2022 04:54 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:HENRY FAMILY CHILD CAREFACILITY NUMBER:
197700166
ADMINISTRATOR:HENRY, ELORINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 220-3340
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elorine Henry TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) King-Lewis conducted a required 1 year Inspection with licensee. LPA observed 1 children in care. LPA was guided on a tour of the home day-care area. The licensee is also a Resource Parent through Fred Jefferson Foster Family Agency license # 197806903. The day care now takes place in the following area of the home: downstairs family room, dining area, hallway bathroom, and back yard. Licensee stated upstairs area of the home is not off limits to day care children. Licensee has stair gates at the top and bottom of the stairs.

Licensee stated she is requesting to change her hours of operation to Monday thru Friday from 6:00 AM - 6:00 PM. Licensee stated she no longer wishes to provide overnight care for day care children. Currently living in the home are licensee, licensee’s spouse, and licensee’s 16 years of age son as well as 4 foster placement.

During the inspection LPA observed the facility Physical Plant, Care and Supervision, Facility Records Review, and Facility Administration.



LPA discussed safe sleep regulation and informed licensee to refer to regulation 102425(J) for documentation requirement. LPA reviewed requirement with licensee during this inspection. Licensee shall supervise infants while they are sleeping by physically checking every 15 minutes and documenting the child status in writing.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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: 07/26/2022
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Licensee was informed all infants shall have an individual infant Sleeping Plan (LIC 9227). Licensee aware no infant shall be swaddle, car seat shall not be used for sleeping, LPA provided Child Care Licensing Safe Sleep web page as an additional resource: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep

Incidental Medical Services (IMS) policy was discussed. To provide Incidental Medical Services, such as administering blood glucose monitoring, inhaled medications, Epi-pen and Epi-pen Jr., insulin shots, gastrostomy tube feeding and care, or carrying out other medical orders, it is best practice to complete a “Plan for Providing Incidental Medical Services”. This plan will help you ensure that you can provide this service in the safest manner possible. A Plan for Providing IMS must be submitted to the Department.

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. The report unusual incident/injuries report should be emailed to UnusualIncidentReport@dss.ca.gov

During this inspection facility was observed to be in compliance with Title 22 regulations.

For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Exit interview conducted and report was reviewed with the licensee a copy of this report and a notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
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