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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016464
Report Date: 06/19/2025
Date Signed: 06/19/2025 01:17:37 PM

Document Has Been Signed on 06/19/2025 01:17 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 SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:VAN LEEUWEN FAMILY CHILD CAREFACILITY NUMBER:
198016464
ADMINISTRATOR/
DIRECTOR:		VAN LEEUWEN, TRINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 522-5192
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
06/19/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Trina Van Leeuwen, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Alicia Mooberry conducted an unannounced Annual Random Inspection on this date. Upon arrival at 10:15 LPA met with Licensee, Trina Van Leeuwen, informed of the purpose of inspection and provided form LIC 126, Inspection Entrance Checklist. The Licensee provided tour of facility. LPA inspected rooms/areas on the facility sketch in which child-care services are provided and to which children have access. Per licensee the current hours of care provided are Monday – Friday 6:30am - 7:00p. There were 6 children present, including 1 infant. Also present was Kenneth Van Van Leeuwen, Assistant. All adults present have obtained the required background clearance and are associated to the facility. Individuals residing in the home were discussed and noted.

This is a single family home consists of two bedrooms, one bathroom, living room, den(day-care room), Kitchen/dining area/laundry area, detached garage, backyard.

Per licensee, the areas used by children include: Living room, den (day-care room), bathroom, Kitchen/dining area/laundry area, backyard area in front of the garage.


Off limit areas: 2 bedroom, backyard (areas sectioned off for family pets), detached garage.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness.

LPA observed the facility license, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form posted inside day-care room. Per licensee, required posted documentation are visible to parent/guardians of children in care. LPA reviewed Children’s Roster form LIC 9040 and Emergency Disaster Plan (LIC 610A) -------- Page 1 – Report Continues

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Alicia Mooberry
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: VAN LEEUWEN FAMILY CHILD CARE
FACILITY NUMBER: 198016464
VISIT DATE: 06/19/2025
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The home is observed to be clean and orderly. There are toys and other age-appropriate material available. The home maintains telephone service via cell phone/LAN line. LPA observed that cleaning compounds and knives are in overheard cabinets in kitchen inaccessible to children in care.

The home has a wall heater with floor vents locate in the living room and hallway barricaded. Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged, LPA observed service tag dated 8/4/24. Licensee was reminded that fire extinguisher needs to be serviced yearly. The bathroom that children use is in the hallway and observed to be clean and free of hazards.


Licensee states that there are no poisons stored in the home and understands that all poisons must be locked, not only inaccessible to children. Per Licensee there are no firearms or weapons stored in the home.

Per Licensee, area for children who are ill is located in the living room, supervised and away from the other children.

Outdoor play area is in the yard and observed to be fenced. LPA observed that the outdoor yard is sectioned off to include pet area and children's play area. The children's play area is located in front of the garage, has shading, toys and other age appropriate materials. The facility does not have a pool or similar bodies of water. Per licensee, the pet(s) roam freely in the home and interact with children, Licensee or staff supervise at all time. LPA discussed water safety with licensee. Per licensee, they use misters, sprinklers for water play, no pools are used.

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, LIC 995A Notification of Parents’ Rights, and documentation of 15-minute Infant Sleep Check (0-24 months). LIC 9227 and Sleep logs reviewed for Infants in care. LPA advised licensee on immunization schedule for children in care and provided website www.CDPH.CA.GOV.

Licensee and Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, 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 and current Mandated Reporter Training Certificate. Heartsaver Pediatric 1st Aid and CPR observed (Exp. 02/2027) for both Licensee and Assistant.

---------- Page 2, Report continues

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Alicia Mooberry
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: VAN LEEUWEN FAMILY CHILD CARE
FACILITY NUMBER: 198016464
VISIT DATE: 06/19/2025
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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.

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.

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 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/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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

Based on the LPA's observations and records review No deficiencies are cited during this inspection.

A notice of site visit was given and must remain posted for 30 days. Appeal Rights were discussed and provided. Exit interview conducted and report was reviewed with the licensee, Trina Van Leeuwen.

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Alicia Mooberry
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
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