198011471-7-22-2024-33-CC-MSIA-D7EMJA-20240722093848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198011471
Report Date: 07/19/2024
Date Signed: 07/22/2024 09:39:01 AM

Document Has Been Signed on 07/22/2024 09:39 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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	CAMPBELL FAMILY CHILD CARE		FACILITY NUMBER:	198011471
ADMINISTRATOR/ DIRECTOR:	CAMPBELL. DONNITA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 733-2737
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 4	CENSUS: 2	DATE:	07/19/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:50 PM
MET WITH:	Licensee Donnita Campbell		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

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 07/19/2024 Licensing Program Analyst (LPA) Mary Silva conducted an unannounced annual inspection at the above facility. LPA met with Licensee, Donnita Campbell, to whom the reason for the visit was explained. LPA was guided on a tour of the facility. Per Licensee, there are 4 children currently enrolled. There were 2 children present upon arrival. The licensee was observed to be operating within the license capacity limitations. Hours of operation are Monday – Friday,7:00am-6:15pm. This is a one-story home which consists of 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, playroom located in the rear of the home, front yard, and backyard which is fenced. Currently residing in the home are two adults (criminal record clearance on file) and no minor children. Per licensee, areas off limits to children and parents include 3 bedrooms, 1 bathroom, kitchen, living room, dining room, and front yard. The children have access to playroom, one bathroom, one bathroom, and backyard which is fenced. Facility License, Emergency Disaster Plan, Parent’s Rights Poster, and Earthquake Preparedness Checklist were observed to be posted in the entry way of the playroom. A current children’s roster was available for review. There is telephone service via a cellphone that stays at the facility during operation hours. There is ventilation and central heating in the home. LPA observed the valve on the required 2A 10BC fire extinguisher indicates fully charged with a service tag dated 06/22/2023. Smoke and carbon monoxide detectors were tested and are operable. Detergents, cleaning compounds, and medications were observed to be inaccessible to children. Per Licensee there are no poisons in the home. ___________________________Page 1___________________________________

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Mary Silva
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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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Document Has Been Signed on 07/22/2024 09:39 AM - It Cannot Be Edited

Created By: Mary Silva On 07/19/2024 at 01:22 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CAMPBELL FAMILY CHILD CARE	FACILITY NUMBER: 198011471
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(1)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, fire extinguisher was serviced in JUne 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Per licensee will have fire extinguisher serviced and verification will be submitted by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Christina Gabelman

LICENSING EVALUATOR NAME:

Mary Silva

LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CAMPBELL FAMILY CHILD CARE	FACILITY NUMBER: 198011471
	VISIT DATE: 07/19/2024

NARRATIVE

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LPA advised that any poisons should be locked under key or combination lock. Licensee states that there are no firearms or weapons stored in the home.

All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Last drill documented was conducted on 06/09/2024. The home is observed to be clean and orderly. There are first aid supplies available. Licensee provides meals for the children in care. There are age-appropriate toys available for children. Appropriate sleeping arrangements in form of cribs and cots were observed. LPA observed three dogs in the front area of home(breed, 2 Senior Boxers and a German Shepherd). Reminded licensee pets must remain in off-limits area during hours of operation.

Per licensee, children are using the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. No bodies of water were observed on this day.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, and LIC 995A Notification of Parents’ Rights.

Licensee’s file was reviewed for the following: LIC 508- Criminal Record Statement, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse. Pediatric First Aid and CPR certification on expires 06/19/2025 for licensee, and for Gabriel Barela. Mandated Reporter Training has been completed and expires on 06/21/2025 for licensee and Gabriel Barela. www.mandatedreporterca.com

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. Licensee does not have infants enrolled. 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.

__________________________________Page 2_______________________________

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Mary Silva
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CAMPBELL FAMILY CHILD CARE	FACILITY NUMBER: 198011471
	VISIT DATE: 07/19/2024

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. 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/process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

MyChildCarePlan.org – Centers and Family Child Care Homes - Licensee, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Megan’s Law - Family Child Care Homes - During the exit interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal rights was given.

Exit interview was conducted and report was reviewed with licensee Donnita Campbell.

___________________Page 3________________________________

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Mary Silva
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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