198021172-3-20-2023-33-CC-SLEE-CQ4NEC-20230320102342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198021172
Report Date: 03/17/2023
Date Signed: 03/20/2023 10:23:48 AM

Document Has Been Signed on 03/20/2023 10:23 AM - 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:	KOBAYASHI FAMILY CHILD CARE		FACILITY NUMBER:	198021172
ADMINISTRATOR:	KOBAYASHI, MESEUN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 774-8488
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	03/17/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Meseun Kobyashi		TIME COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Seung Lee conducted an a prelicensing inspection. Upon arrival LPA Lee met with applicants Meseun Kobyashi . The inspection conducted on this date is for a pending large family child care home application. Applicants stated they wish to provide care for children ages 0-10 years old. Hours of operation will be Monday-Friday 7:40AM-6PM. The following was observed. The large family child care home consists of 4 bedrooms, 3 restrooms, kitchen, backyard and living room. The off limits areas were the 2 bedrooms, and 1 bathroom, the kitchen, and backyard Children will be cared for in the living room, 2 bedrooms, 2 bathrooms. and parts of the frontyard. Adults living in the home are the applicant and applicant's spouse. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. There are age appropriate toys and napping equipment on the premises. Per applicants there are no firearms or pets in the home. LPA Lee observed that the fire extinguisher was the appropriate size but there was no receipt or tag available to review. The two applicants CPR and first aide expires 01/2025. LPA observed a operational smoke and carbon monoxide detector located in the bedrooms that will be used for the day care. Fire extinguisher is located near the front entrance with a service tag date of 04/12/22. LPA reviewed Sudden Infant Death Syndrome (SIDS), Shaken Baby Syndrome, and safe sleep practices with applicant. Infants should always sleep on their backs, mouths facing up, light bedding.

SUPERVISORS NAME: Guangorena Claudia
LICENSING EVALUATOR NAME: Seung Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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

FACILITY NAME: KOBAYASHI FAMILY CHILD CARE	FACILITY NUMBER: 198021172
	VISIT DATE: 03/17/2023

NARRATIVE

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The following was reviewed during this inspection.
FORMS TO BE POSTED
LIC6101A Emergency Disaster Plan,
PUB394 Notification of Parents Rights Poster,
Facility License
Facility Records: LIC 624B Unusual Incident/Injury Report,LIC 9040 Child Care Facility Roster, LIC 9052 Employee Rights,LIC 9108 Statement Acknowledging Requirement to Report Child Abuse,
Staff Forms/Records - any assistant present must have the following on file: Proof of TB clearance (within one year), Immunization records. Notice of Employee Rights (LIC 9052), Criminal Record Statement (LIC 508), Statement Acknowledging Requirements to Report Suspected Child Abuse (LIC 9180).
Children’s records requirements: LIC 700 Identification And Emergency Information, LIC 627 Consent For Emergency Medical Treatment, LIC 282 Affidavit Regarding Liability Insurance, LIC 9150 Parent Notification Additional Children In Care, Immunization record, PUB 72- Family Child Care Consumer Guide, LIC 995A Notification of Parent’s Rights

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,TB clearance, and a valid criminal record clearance associated to the facility license.
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.
The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked and batteries replaced as needed.

SUPERVISORS NAME: Guangorena Claudia
LICENSING EVALUATOR NAME: Seung Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: KOBAYASHI FAMILY CHILD CARE	FACILITY NUMBER: 198021172
	VISIT DATE: 03/17/2023

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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.
Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Mandated reporter requirements was reviewed and explained.
Fire and safety drills must be performed every month and documented for review by the Department.
Smoking is prohibited in a family child care home, 24/7.
Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
All adults living and working in the home shall be made of aware of the Departments right to inspection authority.

Once licensed applicant was informed to contact the department 30 days prior to enrolling any child with IMS needs. LPA advised applicant to refer to Section 101173 and 101226 for further information on regulatory requirements. Regulation Interpretations and Procedures for Child Care Centers Section 102417. 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.

Once licensed, the applicant is required to adhere to the terms and limitation as stated on the license.
LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing Website at: www.ccld.ca.gov

LPA Lee observed no needed corrections during the inspection. The applicant was advised that the license will be granted after the application along with this report is submitted for processing. Exit interview conducted with applicant Meseun Kobyashi Appeal rights discussed and explained.

SUPERVISORS NAME: Guangorena Claudia
LICENSING EVALUATOR NAME: Seung Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC809 (FAS) - (06/04)

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