198020979-3-17-2022-33-CC-BBAT-CBYVAN-20220225151613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020979
Report Date: 02/25/2022
Date Signed: 03/17/2022 12:26:32 PM

Document Has Been Signed on 03/17/2022 12:26 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	CHAVARRIA FAMILY CHILD CARE		FACILITY NUMBER:	198020979
ADMINISTRATOR:	NICOLE CHAVARRIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 361-0773
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	02/25/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Licensee, Nicole Cuervo Chavarria		TIME COMPLETED:	03:30 PM

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	-This an amended version of the report issued to the facility on 02/25/2022 to reflect changes to the capacity being requested, the type of license held by the applicant and number of bedrooms in home. Licensing Program Analyst (LPA) Bardo Baluyot conducted an announced Pre-Licensing inspection. COVID risk assessment was conducted after entry. Upon arrival LPA met with Applicant, Nicole Cuervo Chavarria. Licensee's fiancee/Assistant was also present during the inspection. Applicant is requesting a change of location for her Small Family Child Care License. The former license was located at 610 N. Howard Ave. #43 in the city of Montebello. (198020243) and is requesting to relocate to 1041 East Swanee LN. West Covina 91790. The facility is a one story 3 bedroom, 2 bathroom home but the day care area will be in an adjacent area with a separate entrance but also accessible through the kitchen. Individuals residing in the home are the Applicant and her fiancee/Assistant. Applicant guided LPA on a tour of the facility both indoors and outdoors. The day care area consists of a separate living room/den on the opposite side of the main area of the home. There is a door leading to the garage which will be kept locked at all times. The restroom available for children in care is adjacent to the kitchen. There is a door leading to a bedroom which will be kept locked when children are present and is equipped with a safety lock. The main areas of the home will be off limits and include 3 bedrooms and 1 bathroom the kitchen, dining room and living room are off limits. The home was inspected for safety, comfort, cleanliness, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. There are pets in the home ( 2 caged birds and a dog). Per applicant, child care will be provided from 7:00am to 6:00pm, 7 days a week, 23 hours a day. Licensee understands that care for a child should not exceed 24 hours.

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Bardo Baluyot
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHAVARRIA FAMILY CHILD CARE	FACILITY NUMBER: 198020979
	VISIT DATE: 02/25/2022

NARRATIVE

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Per Applicant, the following areas will be used for day-care: Den/second living room area and 1 bathroom (adjacent to kitchen), and backyard.
Per Applicant, Off-limits areas include: Front yard, 3 bedrooms, 1 bathroom and garage. The doors to the off-limit areas will remain closed during operating hours and also have safety knobs installed.

The applicant has all appropriate forms posted. LPA confirmed with the applicant that all adults residing in the home have obtained criminal record and TB clearance. The facility has a working phone. Licensee has taken the 8-hour First Aid/CPR training, her certificate is valid thru 08/2022. Proof of immunization against influenza, pertussis, and measles for the applicant was readily available during today's inspection. Applicant has completed the Mandated Reporter Training. There is an operational combination smoke and carbon monoxide detector maintained throughout the home and day care room. The valve on the required 2A 10BC fire extinguisher indicates fully charged serviced on 2/8/2022. The home has electrical outlet covers throughout and maintains a First Aid and Emergency Kit. There are some age appropriate materials and sleeping equipment was available for children to be enrolled in care. Per applicant, there are no firearms in the home. The outdoor play area is a fenced backyard. The applicant states that there are no poisons in the home. The applicant does understand that poison must be locked with a key or combination lock. LPA did not observe any bodies of water on the premises.
The following was discussed with the applicant:
· Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.
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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Bardo Baluyot
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHAVARRIA FAMILY CHILD CARE	FACILITY NUMBER: 198020979
	VISIT DATE: 02/25/2022

NARRATIVE

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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. The family day care home shall maintain documentation of the required immunization 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.
· A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.
· Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated.
· The fire extinguisher type 2A10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked and batteries replaced as needed.
· Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

· Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a family child care home.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
· Saucer chairs, bouncers, walkers, or any similar items are prohibited.
· All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
· Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are required to be posted.
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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Bardo Baluyot
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHAVARRIA FAMILY CHILD CARE	FACILITY NUMBER: 198020979
	VISIT DATE: 02/25/2022

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-This an amended version of the report issued to the facility on 02/25/2022 to reflect changes to the capacity being requested, the type of license held by the applicant and number of bedrooms in home.

Applicant states that she will care for infants and that infants will sleep in the den/day care area where they will be constantly supervised. LPA informed Applicant that one crib for each infant in care will be needed. LPA informed Applicant that cribs or play yards shall not hinder the entrance or exit from the sleeping space, mattresses shall be firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Cribs and play yards shall be free of loose articles and objects. No objects shall be hanging above or attached to the side of the crib. LPA informed Applicant that infants cannot be swaddled while in care. LPA advised the Applicant 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. LPA also consulted and explained Child Abuse Reporting, Never Shake a Baby, and Safe Sleeping practices.

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

A small family child care license may be granted after final review of the application. Once licensed, the licensee is required to adhere to the terms and limitation as stated on the license. Exit interview was conducted with Applicant, Nicole Cuervo Chavarria.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Bardo Baluyot
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC809 (FAS) - (06/04)

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