198012190-12-9-2021-54-CC-AJLO-C9JP6W-20211209100301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198012190
Report Date: 12/09/2021
Date Signed: 12/09/2021 12:55:13 PM

Document Has Been Signed on 12/09/2021 12:55 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:	COSTA FAMILY CHILD CARE		FACILITY NUMBER:	198012190
ADMINISTRATOR:	COSTA, EVELYN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 612-1157
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90810
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 2	DATE:	12/09/2021
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Evelyn Costa, Licensee		TIME COMPLETED:	10:30 AM

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	Prior to entrance to the facility, LPA Lucero conducted a COVID-19 assessment and based on the licensee responses to the facility assessment questions, LPA Lucero determined it was safe to proceed. On Thursday, December 9, 2021 at 8:30am, Licensing Program Analyst (LPA) Lucero conducted an unannounced Annual Inspection. LPA met with Licensee Evelyn Costa who guided LPA on an indoor and outdoor tour of the facility. There were two children present at the time of inspection. Family members residing in the home has been discussed with licensee and are cleared. This facility is a one story home that consists of two bedrooms, two bathrooms, kitchen, living room, den that was converted for day care purposes, dining area, attached detached garage, front and backyard. Per licensee, areas accessible to children are the den area, one bathroom located next to den, and back yard. Per Licensee, areas off-limits to children are the rest of the home which consists of kitchen, dining area, living room, two bedrooms, one bathroom. detached garage, and front yard. LPA observed a door to prevent children from gaining access from the den to the rest of the home. Licensee stated she does not care for infants under 12 months of age. At approximately 8:45am, LPA began the facility to inspect for safety, comfort, cleanliness, ventilation and working phone. For ventilation, LPA observed that the facility has windows and a large sliding door for air circulation, and a heater for heating. LPA observed the Children Roster, LIC 610A Emergency Disaster Plan, PUB 394 Parent’s Rights, emergency drills posted on the Parent Board at facility entrance. LPA asked if there are any pets, poisons, firearms, weapons or bodies of water. Licensee stated she has one dog, and no body of waters, firearms, weapons or poisons. LPA did not observe bodies of water on the premises. Licensee was advised that if any poisons (ex: Drano, rat poison or items with skull hazard symbol), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition must be stored separately.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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 3

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: COSTA FAMILY CHILD CARE	FACILITY NUMBER: 198012190
	VISIT DATE: 12/09/2021

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
26
27
28
29
30
31
32

At approximately 08:50am, LPA entered the restroom and observed the toilet, hand washing sink, running water, towel, and hand soap. LPA observed the bottom cabinets closed and with a child proof lock in place making it inaccessible to children to open cabinet doors. LPA observed the restroom to be in good condition.

At approximately 08:55am, LPA observed the required 2A10BC fire extinguisher located in the day care area and the valve on the green area indicating fully charged and a tag with a date of 09/2021. LPA observed the smoke detector and carbon monoxide detector in the den area. At approximately 9:10am, LPA inspected the outdoor area used by children for safety, comfort and cleanliness. LPA observed play equipment to be in good condition and age appropriate.

At approximately 9:30am, LPA conducted a records review. LPA observed licensee’s Pediatric First Aid/ CPR card issued by the American Heart Association with completed date of 09/18/2021. Discussion was held with Licensee regarding the importance of maintaining current Pediatric CPR/First Aid certification. LPA determined that Licensee has completed the Mandated Reporter Training (AB 1207). Licensee was advised that the mandated reporter training 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 web page at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee Evelyn Costa of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at also explained to licensee that car seat, stroller are only and only for https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA discussed protocol in place in regards COVID-19. Applicant stated protocol in place is having parents not fully enter the facility and sign in and out will take place at the front door entrance. The child care area is big enough to meet the 6 feet distance. Applicant will scan the children for any symptoms such as fever, running nose, cough or child's behavior and will inform parent child cannot stay if any symptoms related to COVID-19 or if symptoms appear during the day, applicant will isolate the child and call parent for pick up. Children will wash their hands during arrival, entering the facility from outdoor play, meal times, covering their cough and using the restroom. LPA observed hand washing posters posted in the bathroom and COVID-19 symptoms poster in the front entrance and hand sanitizer for parents (inaccessible to children).

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: COSTA FAMILY CHILD CARE	FACILITY NUMBER: 198012190
	VISIT DATE: 12/09/2021

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
26
27
28
29
30
31
32

Applicant stated she is aware of cleaning, disinfecting and sanitizing and the importance of the constant hand washing. Technical Assistance was conducted with applicant on this date.

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

Licensee Evelyn Costa 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.

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/process

A notice of site visit was given and must remain posted for 30 days. No deficiencies cited during today's inspection.Exit interview conducted and report was reviewed with the licensee Evelyn Costa.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3