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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012488
Report Date: 04/18/2023
Date Signed: 04/18/2023 09:53:53 PM

Document Has Been Signed on 04/18/2023 09:53 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:COOK FAMILY CHILD CAREFACILITY NUMBER:
198012488
ADMINISTRATOR:COOK, AMBERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 701-3931
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Amber Cook, LicenseeTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dayna Chambers conducted an unannounced annual inspection to the above facility on April 18, 2023. LPA arrived at the facility at 8:45AM and met with Amber Cook, Licensee who guided analyst on a tour of the facility. Licensee left the home at 9:35am to attend to emergency. Licensee returned at 10:15am. Licensee left the home again at 12:55pm. Also present during this inspection, was Jordyn Cook and Maria Sandoval, Licensee’s Assistants. Per Licensee, operation hours are 7:00am to 6:00pm Monday through Friday, closed Saturday and Sunday. There are 17 children that are currently enrolled. A children’s roster was available for review but needs to be updated. There were 9 children present upon arrival. This is a one-story home which consists of 3 bedrooms, 2 bathrooms, kitchen, dining room, Den, Activity Room connected to back area, living room, garage is converted into activity area, front yard, and backyard (fenced). The children use the bathroom in the hallway. Per Licensee, areas off limits to children and parents include: all bedrooms, master bathroom, living room. The licensee provides food for children in care.
Individuals who reside in the home were noted and discussed. Per Licensee, they currently have two assistants. LPA observed that one adult present in the home had not obtained a criminal record clearance or exemption prior to working, residing, or volunteering in the licensed childcare home. Licensee states that there are no firearms stored in the home. The licensee provides food for children in care. All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is telephone service via cellphone and the cellphone stays at the facility during operation hours. There is ventilation and heating via fans. Safe toys play equipment and materials were observed. At approximately 9:15am, LPA observed the children's bathroom located in the hallway. The bathroom has a sink and cupboard below right behind the door. The cupboard did not have a lock. LPA observed the following cleaning compounds accessible to children: Ajax, Window Cleaner, Cleaning Products, Soap accessible to children under sink. The second cupboard under the changing table had a broken lock and soap. The licensee repaired the lock under the changing table during the inspection. LPA observed cleaning compounds that need to be inaccessible in the children’s bathroom. LPA advised licensee to remove the items during inspection. LPA did not observe medications or other items that were accessible and pose a danger to children. The licensee
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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 36
Document Has Been Signed on 04/18/2023 09:53 PM - It Cannot Be Edited


Created By: Dayna Chambers On 04/18/2023 at 01:48 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: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, LPA observed cleaning compounds in the childrens restroom under sink behind door which is not locked. Items such as Glass Cleaner, Ajax, other compounds, see photo, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2023
Plan of Correction
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Remove the items immediately, add lock to the sink behind the door. The licensee fixed the lock underneath the changing table during inspection. Read the Title 22 Operation of FCCH provided to licensee and train staff. Take photo of the sink behind door when locked is installed and send to LPA
Type A
Section Cited
CCR
102425(a)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Child #4 - does not have a crib or play yard to nap, see photo, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Infant is not to sleep on the floor. LPA provided all safe sleep materials to Licensee. Licensee is to train the staff on safe sleep, take photo of the play yard provided for infant #4 and send to LPA by 04/24/23.
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:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 2 of 36
Document Has Been Signed on 04/18/2023 09:53 PM - It Cannot Be Edited


Created By: Dayna Chambers On 04/18/2023 at 01:48 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: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review in Guardian, Staff #2 who is also licensee daughter, moved back in the home in September 2022. The background process was not completed with clearances before working, living at the home (since 09/2022), the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2023
Plan of Correction
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LPA provided licensee with CPMB phone number and will contact them to find out why the status is IN PROCESS. LPA will follow up with Guardian. Licensee will notify LPA of status. Licensee has an additional cleared staff to supervise Staff #2. This is also the licensee's daughter.
Type A
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 observation, record review, Licensee and two staff have expired CPR cards -03/08/23, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee and both staff will take the CPR this weekend and provide LPA with proof of completion by email when completed. Due date 04/24/23.
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:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 13 of 36
Document Has Been Signed on 04/18/2023 09:53 PM - It Cannot Be Edited


Created By: Dayna Chambers On 04/18/2023 at 01:48 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: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

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
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Based on observation and record review, the last drill was conducted on 0919/2022 (today is 04/18/23) , the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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LIcensee and staff will conduct a drill by 04/21/23 and send LPA the documented drill log with the date completed by email
Section Cited
Infant Safe Sleep
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:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 11 of 36
Document Has Been Signed on 04/18/2023 09:53 PM - It Cannot Be Edited


Created By: Dayna Chambers On 04/18/2023 at 01:48 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: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, Child #4 did not have a sleep chart created and has been enrolled since January 8, 2023. the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Create a sleep chart and log until 04/28/23. Email LPA with a completed log conducting the 15-min checks
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 and observation, Staff #2 did not have a mandated reporter available during inspecction, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee will create a file for Staff #2 and send the completed mandated reporter certificate by email to LPA by 04/24/23.
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:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 29 of 36
Document Has Been Signed on 04/18/2023 09:53 PM - It Cannot Be Edited


Created By: Dayna Chambers On 04/18/2023 at 01:48 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: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reveiw and observation, the licensee does not maintain documentation of the immunizations for licensee or staff in files ready for review, the licensee did not comply with the section cited above] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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LIcensee to create staff files for licensee, both assistants, with all of the required documents including immunization records and be availble for review. Send photo to LPA of completed staff files by 04/24/23.
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observation, licensee does not have completed files for staff or licensee with required documents, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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3
4
Licensee to create staff facility files with complete required documents - LPA provided 311D licensing form to assist creating the files. LIcensee will take a photo by 04/24/23 and email to LPA
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:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 22 of 36
Document Has Been Signed on 04/18/2023 09:53 PM - It Cannot Be Edited


Created By: Dayna Chambers On 04/18/2023 at 01:48 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: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on record review and observation, the staff and licensee's immunization records are not maintained and available for review during inspection, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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2
3
4
Create facility files that include all immunization records and send photo to LPA of MMR, TDAP, TB Clearances, and Influenza or declination form by 04/24/23
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:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 36 of 36
Document Has Been Signed on 04/18/2023 09:53 PM - It Cannot Be Edited


Created By: Dayna Chambers On 04/18/2023 at 01:48 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: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observation, Child #2 was missing immunization records, including the immunization records that need to be printed out from the phone and placed in the files, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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2
3
4
Using the 311D licensing form, check the children's files for required documents and print out all immunizations from phone and place in the files and obtain the missing immunization records for child #2. Email a photo of corrected files by 04/24/23.
Section Cited
Immunizations
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:Valarie Cook
LICENSING EVALUATOR NAME:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 15 of 36
Document Has Been Signed on 04/18/2023 09:53 PM - It Cannot Be Edited


Created By: Dayna Chambers On 04/18/2023 at 01:48 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: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(c)
Child's Records
(c) In any case in which the licensee cares for an additional child pursuant to Section 102416.5(b) for a Small Family Child Care Home or Section 102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child’s record, a copy of documentation verifying the child’s enrollment and attendance at kindergarten, including transitional kindergarten, or elementary school as required in Section 102416.5(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observation, Child #2 needs proof of enrollment, , the licensee did not comply with the section cited above] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
1
2
3
4
Licensee to obtain proof of enrollment of all enrolled children that are enrolled or attending kindergarten or elementary. Email proof of attendance to LPA by 04/24/23.
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observation, the files did not have an affidavit for liability insurance. the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
1
2
3
4
Update all files with the affidavit and show proof to LPA by 04/24/23.
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:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 3 of 36
Document Has Been Signed on 04/18/2023 09:53 PM - It Cannot Be Edited


Created By: Dayna Chambers On 04/18/2023 at 01:48 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: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observation, Child #4 did not have LIC9227 in file, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
1
2
3
4
The child is now 11 months old, licensee needs to create a practice one for the child and show proof by 04/24/23 email LPA
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observation, no sleep chart for Child #4, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
1
2
3
4
Email LPA a completed sleep chart by May 5, 2023 for chlid #4. Read the safe sleep Title 22 regulations and Safe Sleep FAQs and train staff.
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:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488
VISIT DATE: 04/18/2023
NARRATIVE
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states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock. The restroom that children use was observed to be safe and sanitary.
The valve on the required 2A 10BC fire extinguisher indicates fully charged had a receipt dated and was serviced on 0919/2022. Smoke and carbon monoxide detectors were tested and are operable. LPA recommended installing a carbon monoxide and smoke detector in the activity room by the kitchen. The working carbon monoxide and smoke detectors are in the living room on the other side of the kitchen. Licensee states that she is currently caring for infants. Licensee states that infants sleep in the activity room where they are constantly supervised. LPA observed that child #4 did not have appropriate sleeping arrangements. LPA took photo. LPA observed infant sleeps on the floor on a cot, blanket, and pillow. LPA asked the assistant if they have a play yard or crib, and the answer was no. LPA provided Infant Safe Sleep Regulation Title 22, PIN- 20-24, Safe Sleep FAQs, Sleep Chart, and LIC9227 and advised licensee to train staff in addition to reading the regulations on the Department Website. LPA did not observe any infants swaddled while in care. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age. A copy of the LIC 9227 was provided to Licensee. a copy of the Provider Information Notice (PIN) 20-24 CCP: Recently Approved Safe Sleep Regulations in Effect.
Currently, children are using the backyard 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. LPA did not observe any objects that can pose a danger to children on the outdoor yard. The licensee is observed to be operating within the license capacity limitations. LPA did not observe any children left in parked vehicles. Car seats shall only be used for transportation. LPA did not observe any children sleeping in car seats.
The licensee and other personnel did not have current EMSA approved training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expired on 03/08/2023. Assistants CPR expired on 03/08/23. There are first aid supplies available. LPA advised that if a child shows signs of illness, he/she/they shall be separated from other children. Children’s records were reviewed, including emergency information, and were observed to be incomplete. The licensee did not have a facility file to provide during inspection with proof of immunizations: MMR, TDAP, TB Clearance, or Influenza or declination. LPA observed that one assistant does not have proof of the Mandated Reporter AB 1207 compliant Child Care Training Certificate on file. Licensee has a certificate for Associate Clinical Social Worker.LPA issued a Confidential Names List (LIC 811) to the licensee which documents staff and children’s files reviewed during this inspection.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488
VISIT DATE: 04/18/2023
NARRATIVE
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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 09/19/2022, which is past due. Per licensee, there are no pets on the premises. LPA did not observe any pools, spas, hot tubs, fishponds, or similar bodies of water during the inspection. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories are not permitted in a family childcare facility. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home. LPA provided the licensee with a copy of A Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. LPA also consulted and explained Child Abuse Reporting, Never Shake a Baby, and Safe Sleeping practices. Licensee left the home at 12:55pm before the inspection was completed.
Incidental Medical Services (IMS):
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.
LPA advised the licensee to access forms, regulations, and quarterly updates online at: www.ccld.ca.gov.
Licensee 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.
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 [facility representative] 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 and must remain posted for 30 days.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
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: COOK FAMILY CHILD CARE
FACILITY NUMBER: 198012488
VISIT DATE: 04/18/2023
NARRATIVE
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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. The following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

TYPE A ----A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee/Director was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee/Director.


Exit interview was conducted with Jordan Cook, Assistant, including, but not limited to Appeal Procedures/appeal rights, Site Visit, and agency’s consultative role.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
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