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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700170
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:41:35 PM

Document Has Been Signed on 06/07/2022 03:41 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:DONN FAMILY CHILD CAREFACILITY NUMBER:
197700170
ADMINISTRATOR:DONN, AMAKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 992-1401
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Amaka Donn, Licensee TIME COMPLETED:
03:50 PM
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On 06/06/22 Licensing Program Analyst (LPA) Justeene Tamayo met with Licensee, Amaka Donn, who guided analyst on a tour of the facility for the One Year Required inspection. LPA observed a tri level story home, 5 bedrooms, 5 bathroom, 1 level, 1 bedroom, 1 bathroom, kitchen, dining room, living room/playroom, 3 car garage, rear yard. Second level, laundry room, loaf 3 bedrooms, 3 bathrooms. 3 level 1 bedroom 1 bathroom. Licensee states the Home off limit areas are the entire up stairs area, kitchen, and garage. There is no pool/spa or body of water on the premises. Upon arrival LPA observed 3 children in care. Family members residing in the home include 2 adults (licensee and adult son) and no children. Facility operation are Monday-Sunday. Per licensee she is open for overnight care. LPA reminded Licensee care provided during the day and overnight combined shall not exceed 24 hours from the time the children enter the facility. Incidental Medical Services (IMS) policy was discussed.

Physical Plant: Main care is provided in the family room/playroom. Children use the bathroom in hallway on the right (downstairs). The garage is used for storage only and no child care activities are conducted in garage. The area of the home accessible to the children are down stairs bathroom, and living room/playroom. Licensee states she take children to park for outdoor play. There is a fireplace located in off limit living room, inaccessible to children with screen barrier. The home has central heating and air conditioning. The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (in garage with key lock), medicines (master bedroom upstairs ) and hazardous items (sharp knives in upper kitchen cabinet unreachable to children in care with child lock) that can pose a danger to children. Safe and age appropriate toys, play equipment and materials. The smoke detector and carbon monoxide detector, Fire Extinguisher (3A10BC) are in operable condition. Per Licensee no one smokes in the home. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment were observed on the premises. There is a designated area for ill children as necessary in the hallway next to the entrance. Per Licensee there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (cell).
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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: DONN FAMILY CHILD CARE
FACILITY NUMBER: 197700170
VISIT DATE: 06/07/2022
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Last Fire/earthquake drills was completed on 05/13/22. Roster complete and maintained current.

Bathroom: Shower/tub are free of hazards (child care bathroom). LPA did not observe any hazardous items in the children's bathroom. Toilet and faucet are clean and operable. LPA observed cabinets under sink to be locked with child lock inaccessible to children in care.

Kitchen: Sharp utensils, open bottles or alcohol are inaccessible. If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. The home has a clean and fully stocked refrigerator/freezer. Cleaning supplies are in the garage (off limit with key lock). LPA also observed cleaning supplies in the upper kitchen cabinet with child lock inaccessible to children in care. LPA observed sharp knives in upper cabinet above stove with child lock. Breakfast, lunch, snacks and dinner are provided. LPA observed 3 twin beds for children to nap in the main care area.

Outdoor: Per licensee, children do not have access to the backyard. Per Licensee, the backyard door remains locked. Licensee transports children to the park for outdoor activities. Licensee's car insurance and drivers license are current. There is no pool, spa or other bodies of water on the premises. The backyard is completely fenced (with block cement).

Advisory/Other: First Aid kit was observed with supplies readily available. CPR/First Aid expire 08/01/2023. Mandated Reporter expired on 07/27/2021. Licensee will complete the mandated reporter training today 06/07/22 and email the current certificate to LPA Tamayo. There are no window cords accessible to children.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
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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: DONN FAMILY CHILD CARE
FACILITY NUMBER: 197700170
VISIT DATE: 06/07/2022
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Documents Provided and or Discussed: Mandated Reporter Training, Roster, and Safe Sleep PIN 20-24-CCP. Licensee stated currently does not have child care insurance.

During children's file review, LPA did not observe children's immunization records in their files. Licensee will have parents fill out immunization record, and licensee will put in children's files. Licensee will send a copy of records to LPA for proof of completion. Facility is cited a Type B Citation. Please see LIC 809-D.

Licensee Donn was reminded that all adults 18 and over living or working in the home, 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.

LPAs discussed the safe sleep regulations with licensee Donn 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 to licensee and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Amaka Donn, along with her appeal rights.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/07/2022 03:41 PM - It Cannot Be Edited


Created By: Justeene Tamayo On 06/07/2022 at 03:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: DONN FAMILY CHILD CARE
FACILITY NUMBER: 197700170

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview record review, the licensee did not comply with the section cited above. LPA observed children's files did not have their immunizations,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2022
Plan of Correction
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Licensee will email current immunization records to LPA Tamayo for proof of completion.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mariela Ramon
LICENSING EVALUATOR NAME:Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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