198012190-10-5-2023-54-CC-AWAN-CWBU6Y-20231005151907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198012190
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:19:18 PM

Document Has Been Signed on 10/05/2023 03:19 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
MONTEREY PARK S WEST, 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:	DATE:	10/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Licensee, Evelyn Costa		TIME COMPLETED:	03:45 PM

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On October 5,2023 at 1:30 pm, Licensing Program Analysts (LPAs) Angelica Wallin and Raul Navarro, conducted an unannounced Annual Required Inspection and was met by Licensee, Evelyn Costa. Hours of operation are from Monday through Friday, 8:00 AM – 5:00 PM. LPAs toured the home inside and outside and a census was taken.

This one - story home consists of 1 bedrooms and 2 bathrooms. Areas used by the children include: the day care room in back of the home, one (1) restroom in the day care room and side yard next to daycare room. Per Licensee Costa, areas off limits to children include: 1 bedrooms, 1 bath, the kitchen, front and back yard. There was 1 child present during time of inspection. Licensee Costa states that there are currently 10 children enrolled in the facility.

All poisons are kept in a locked storage area. Detergents, cleaning compounds and other hazardous items are made inaccessible. There is a working smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. During inspection, LPAs observed fire extinguisher was serviced on October 28, 2022. Licensee stated fire extinguisher was serviced in June 2023. Licensee stated she will contact service provider for updated tag.

During inspection, safe toys and play equipment were observed. The home has a working telephone service. The outdoor play area in the front yard is fenced and there are no hazards to children present. LPAs observed there no swimming pool or bodies of water. Per licensee, no firearms are kept on premises. Per licensee, food service is provided. Per licensee, overnight care is not provided at this time. Per licensee, no transportation service is provided at this time.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Angelica Wallin
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COSTA FAMILY CHILD CARE	FACILITY NUMBER: 198012190
	VISIT DATE: 10/05/2023

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LPAs reviewed 1 child’s files and observed that child’s file is maintained and updated. A review of staff records indicates that licensee has updated pediatric CPR/First Aid certificate dated 8/2023 with expiration date of 8/2025 and updated immunization records on file for measles, pertussis, influenza and TB clearance. Per licensee, mandated reporter certificate has not been updated to current year because no class is provided in native language.

LPAs reviewed the following documentation to be kept in facility: facility license, LIC610A, PUB 394, and LIC9040. LPAs observed fire drill logs has not been updated since October 2022. LPAs informed licensee Costa regarding importance of conducting fire drills every 6 months. Type B citation issued.

Licensee Costa was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family childcare home during the hours of operation. LPAs reviewed with licensee items prohibited in FCCH, no baby bouncers, no infant walkers, No Johnny jumpers, no saucer chairs, and any other item that falls into that category are not permitted in the facility.

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.

Licensee stated no infant care is provided at this time. LPAs discussed the safe sleep regulations with licensees and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPAs 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.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Angelica Wallin
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COSTA FAMILY CHILD CARE	FACILITY NUMBER: 198012190
	VISIT DATE: 10/05/2023

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This facility does not provides Incidental Medical Services – IMS. 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/

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

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/inspection-process.

Exit interview conducted and report was reviewed with licensee, Evelyn Costa.

During the exit interview, licensees confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Angelica Wallin
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/05/2023 03:19 PM - It Cannot Be Edited

Created By: Angelica Wallin On 10/05/2023 at 02:49 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: COSTA FAMILY CHILD CARE	FACILITY NUMBER: 198012190
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in maintaining fire drill logs which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2023
	Plan of Correction
1 2 3 4	Licensee to conduct fire drill and submit via mail once completed.

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:

Karen Chambers

LICENSING EVALUATOR NAME:

Angelica Wallin

LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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