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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011765
Report Date: 08/31/2022
Date Signed: 08/31/2022 01:08:01 PM

Document Has Been Signed on 08/31/2022 01:08 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:ANTONINI FAMILY CHILD CAREFACILITY NUMBER:
198011765
ADMINISTRATOR:ANTONINI, MARLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 420-2396
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 10DATE:
08/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Marla AntoniniTIME COMPLETED:
01:30 PM
NARRATIVE
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On August 31, 2022 at 10:00 AM, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced inspection at the facility noted above and met with Licensee, Marla Antonini. The purpose of the inspection was to conduct the Required - 1 Year inspection. The operating hours of the facility is Monday through Friday from 7:00 AM to 5:30 PM. Entrance Checklist (LIC 126) was provided to the Licensee upon arrival. Individuals residing in the home were discussed and noted. At the time of the inspection, the Licensee, Licensee's Assistant (S1), and ten (10) children were present. Per Licensee, she does not have a dual license at this address.

All areas identified on the facility sketch were inspected. This facility is a single family home that consists of four (4) bedrooms, one (1) bathroom, living room, dining room, kitchen, laundry room, sun room, detached garage, fenced backyard, and fenced hot tub area.

Areas that are accessible to children include: two (2) bedrooms, 1 bathroom, dining room, kitchen, sun room, and fenced backyard. Per Licensee, the children utilize the fenced backyard for outdoor activity.

Areas off-limits to children include: 2 bedrooms, living room, laundry room, small area that is fenced in the backyard, fenced hot tub area, and detached garage. LPA observed child safety knobs installed, making the 2 bedrooms, laundry room, and access to the master bedroom from the bathroom inaccessible to children in care. LPA observed the garage door from the backyard closed and locked, making the inside of the garage inaccessible to children in care. LPA observed a gate located on the side of the house, making a small portion of the backyard inaccessible to children in care. LPA also observed a gate that meets Title 22 regulations installed to make the hot tub inaccessible to children in care. Per Licensee, the hot tub is empty and is not in use.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Monique Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 08/31/2022 01:08 PM - It Cannot Be Edited


Created By: Monique Ayala On 08/31/2022 at 11:39 AM
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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ANTONINI FAMILY CHILD CARE
FACILITY NUMBER: 198011765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the Licensee and Licensee's Assistant do not have a current Mandated Reporter certificate of completion which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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The Licensee and Licensee's Assistant will complete or renew the required Mandated Reporter Training (AB 1207), and the Licensee will submit proof of completion to LPA via e-mail by September 30th.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the Licensee and Licensee's Assistant do not have on record completion of the Preventative Health and Safety Practices which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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The Licensee and Licensee's Assistant will complete the Preventative Health and Safety Practices course (EMSA-approved), and the Licensee will submit proof of completion to LPA via e-mail by September 30th.
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:Valarie Cook
LICENSING EVALUATOR NAME:Monique Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2022 01:08 PM - It Cannot Be Edited


Created By: Monique Ayala On 08/31/2022 at 11:39 AM
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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ANTONINI FAMILY CHILD CARE
FACILITY NUMBER: 198011765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 10 children's records (C7) did not have the Identification and Emergency Information (LIC 700), and 2 out of 10 children's records (C2 and C7) did not have the Consent for Emergency Medical Treatment (LIC 627). which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee will submit to LPA via e-mail the completion LIC 700 form for child (C7), and LIC 627 form for C2 and C7 by September 30th.
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:Valarie Cook
LICENSING EVALUATOR NAME:Monique Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2022 01:08 PM - It Cannot Be Edited


Created By: Monique Ayala On 08/31/2022 at 11:39 AM
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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ANTONINI FAMILY CHILD CARE
FACILITY NUMBER: 198011765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 10 children's records (C7 and C8) did not have the Notification of Parents' Rights (LIC 995A) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee will submit to LPA via e-mail the completed LIC 995A form for C7 and C8 by September 30th.

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:Valarie Cook
LICENSING EVALUATOR NAME:Monique Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022


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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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: ANTONINI FAMILY CHILD CARE
FACILITY NUMBER: 198011765
VISIT DATE: 08/31/2022
NARRATIVE
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LPA did not observe any barriers making the living room (off-limit area) inaccessible to children in care. Per Licensee, children are dropped off and picked up from the front door, and are walked through the living room to access the designated child care areas. Licensee stated that she will install child safety gates to the dining room and hallway door frames to make the living room inaccessible to children in care. Licensee will submit photographs of the installed child safety gates to LPA via e-mail. The Licensee was advised that off-limit areas must be made inaccessible during operating hours.

The following documents were posted in a prominent, publicly accessible area: Facility License, Notification of Parents' Rights (PUB 394), Earthquake Preparedness (LIC 9148), and Emergency Disaster Plan (LIC 610A). The Licensee had verification of disaster and fire drills available for review. The last drill was conducted on August 18, 2022. The Licensee also has a current Facility Roster (LIC 9040) available for review.

Areas used by children were inspected for safety, comfort, heating, cleanliness and telephone service. LPA did not observe any wall heaters or fireplaces in the facility. The facility has central air and heating. Detergents, cleaning compounds and medicines were made inaccessible to children in care. Per Licensee, there are no poisons kept in the home. Licensee was advised that if any poisons are purchased, it is required to be locked with a key or combination lock.

The facility has firearms and ammunition on the premises that are properly stored per Title 22 regulations. The Licensee has a dog and cat that are kept in one of the off-limit bedrooms. LPA observed age appropriate toys and napping equipment for children. LPA observed electrical outlet covers installed in the child care areas. LPA observed the required fire extinguisher (2A-10BC) that was purchased on August 25, 2022 and is fully charged. Licensee was reminded to have the fire extinguisher serviced yearly. Per Licensee, the smoke detector and carbon monoxide detector are attached to the ADT system that is checked by the Fire Department annually. First Aid kit and emergency supplies are available and kept in the sun room.

Licensee stated that she provides meals and snacks to the children. Per Licensee, children do not bring food from home. Licensee was reminded that food brought from the child's home shall be labeled with the child’s name and properly stored or refrigerated.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Monique Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
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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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: ANTONINI FAMILY CHILD CARE
FACILITY NUMBER: 198011765
VISIT DATE: 08/31/2022
NARRATIVE
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LPA conducted a record review of 10 children's records, the Licensee's and S1. Based on the record reviews, child (C2) did not have the Consent for Emergency Medical Treatment (LIC 627); C7 did not have the Identification and Emergency Information (LIC 700), LIC 627, and Notification of Parents' Rights (LIC 995A); and C8 did not have the LIC 995A available for review.

Based on the personnel record reviews, the Licensee and S1 did not have a current certificate of completion for the Mandated Reporter Training (AB 1207) and Preventative Health and Safety Practices (EMSA-approved). Licensee and S1 have proof of immunization for pertussis and measles. Licensee and S1 have on record a TB clearance and decline declaration statement for influenza. Licensee has a valid Pediatric First Aid and CPR certification (expires February 20, 2023). Licensee was advised that the Mandated Reporter training (AB 1207) must be completed every 2 years and is available at 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. 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.

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.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Monique Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
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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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: ANTONINI FAMILY CHILD CARE
FACILITY NUMBER: 198011765
VISIT DATE: 08/31/2022
NARRATIVE
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Licensee was reminded that all adults 18 and over living in the home, persons who provide 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 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PINs), Program Quarterly Update Newsletters and other important information communication platforms.

LPA provided assistance to the Licensee on how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/inspection-process.

Deficiencies were cited per Title 22 regulations (refer to deficiency pages).

Licensee will submit to the Department an updated Application for a Family Child Care Home License (LIC 279) and Current Children in your Home (LIC279B) by Tuesday, September 6th.

A Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Licensee, Marla Antonini. Appeal rights were explained and provided to the facility representative.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Monique Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC809 (FAS) - (06/04)
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