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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400263
Report Date: 12/22/2021
Date Signed: 12/22/2021 01:11:40 PM

Document Has Been Signed on 12/22/2021 01:11 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:DORLUS FAMILY CHILD CAREFACILITY NUMBER:
198400263
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 4CENSUS: 3DATE:
12/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jessieka Dorlus, LicenseeTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA)Katrina Chicote conducted an Unannounced Required – 1 Year inspection to the above facility on 12/22/2021 at 10:40 AM. LPA conducted COVID-19 screening call prior to entering facility. Upon arrival, LPA disclosed the purpose of the inspection and met with Licensee, Jessieka Dorlus, who guided the LPA on a tour of the facility. Individuals in the home were discussed and all have criminal record clearance. There was three infants present during today’s inspection. Licensee states that there are currently four children enrolled (3 infants and one toddler). The children's roster was reviewed and is current. Per licensee, the facility’s hours of operation are 6:00 AM to 6:00 PM Monday thru Friday. Emergency Disaster Plan, License, and Parents’ Rights were posted at the time of inspection. Per Licensee, she has not conducted a disaster drill log within the six months which is a potential health, safety, and personal rights risk to children in care.

This is a single story home which consists of three bedrooms and two bathrooms, kitchen, dining room, and living room. Areas used by the children include the living room (located upon entry), dining room (located next to living room), Bathroom 1 (located past dining room down hallway to the right of the home), Bedroom 1 (Playroom), and Bedroom 2 (used for Infant Sleeping). Per Licensee, areas off limits to children and parents include Kitchen and Bedroom 3 and Bathroom 2 (located inside Bedroom 3). At 10:43 AM, LPA observed that there is an operable baby gate separating areas used by children and off-limits area.

All areas identified on the facility sketch as accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. There is a working telephone maintained in the home. At 10:47 AM, LPA observed Bedroom 1(Playroom) to have cubbies with
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SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: DORLUS FAMILY CHILD CARE
FACILITY NUMBER: 198400263
VISIT DATE: 12/22/2021
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children's belongings, plastic manipulative toys, blocks, and other age appropriate toys, free of loose and sharp parts available for children at time of inspection. LPA observed electrical cover outlets all through the home. At 10:49 AM, LPA observed Bathroom 1 to have operable toilet and sink, and floor free of hazards at time of inspection. At 10:51 AM, LPA observed Bedroom 2 (Infant Room) to have two cribs meeting Title 22 regulations for safe sleep and an infant changing table. At 10:54 AM, LPA observed dining room, which children will use for eating to have tall dining table and chairs, and three infant feeding chairs that sit on the ground. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible. At 11:00 AM, LPA observed off limits Kitchen area to have operable child safety locks on low cabinets, knives kept on high kitchen counter, detergents and cleaning compounds to be kept in laundry closet in off limits kitchen area. The Licensee states that there are no poisons in the home. The Licensee does understand that poison must be locked with a key or combination lock.

Per Licensee, the children will have access to backyard for outdoor play. Licensee states children have access to backyard through front door and walking down driveway. Licensee and LPA were unable to access backyard at time of inspection due to a car blocking driveway access. LPA observed backyard through Licensee's bedroom window. LPA observed backyard has turf grass and adequate perimeter fencing through-out the yard. At 11:03 AM, LPA observed car track, small cars, and other age appropriate toys free of loose and sharp parts available for the children in the backyard. LPA observed shaded sitting area to the rear of backyard. At 11:05 AM, LPA observed a medium sized dog playing loose in the backyard. Licensee states the dog's breed is a pitbull and is kept separate in a dog run area to the rear of home. LPA observed a separate gated area in the rear of home that Licensee states is the dog's area. LPA observed high fencing that has enough space for children's hands to poke through. Licensee states that she is in the process of installing extra fencing to prevent children's hands from poking through and accessing dog, though Licensee states dog is friendly with the children. LPA observed dog to come close to window but not bark at children at time of inspection.
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SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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: DORLUS FAMILY CHILD CARE
FACILITY NUMBER: 198400263
VISIT DATE: 12/22/2021
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Per Licensee, there are no weapons, firearms in the home and there are no bodies of water around the premises. LPA observation did not see these items around the premises. Per Licensee, they provide food for children in care.

Per Licensee, when a child is showing signs of illness they will be isolated in reading nook area. LPA observed reading nook area to be in hallway between playroom and Infant Sleeping area.

At 11:03 AM, LPA observed the valve on the required 2A 10BC fire extinguisher indicates fully charged and Licensee provided proof of purchase receipt. At 11:07 AM, LPA observed dual smoke and carbon monoxide detectors are in operable condition at time of inspection. Per Licensee, First Aid kit is kept in the laundry room closet in kitchen, at 11:04 AM LPA observed First Aid kit and was inventoried for necessary supplies. The Licensee has current Pediatric First Aid and CPR. Proof of immunization against influenza, pertussis, and measles was readily available during today’s inspection. The Licensee has also taken the Mandated Reporter Training
—CPR Card valid until: 07/19/2022
—Fire Extinguisher was purchased on: 07/2020
—Mandated Reporter AB1207 Completed: 05/28/2020
—Children records and required licensing forms were discussed.

The following were discussed:
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
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SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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: DORLUS FAMILY CHILD CARE
FACILITY NUMBER: 198400263
VISIT DATE: 12/22/2021
NARRATIVE
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Licensee (or facility representative) 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.

Rooms that are off-limits need to be made inaccessible during operating hours. NO smoking, NO infant walkers, NO Johnny jumpers, NO saucer chairs, NO incline sleepers and any other item that falls into that category are permitted in the facility. Effective January 1, 2010, licensees of family child care homes are required to ensure that at least one staff member with current training in pediatric first aid and pediatric CPR is on site at all times when children are present.



The Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care.

LPA discussed the safe sleep regulations with licensee [or facility representative] 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.

LPA reviewed and issued the LIC 311D - Forms/Records to Keep in Your Family Child Care Home. Mandatory Forms for the children’s files and staff files, requirements for fire drills, earthquake drills and documentation were discussed. Role and responsibilities of being a Mandated Reporter were reviewed. The Licensee was advised how to access forms and Regulations online at www.ccld.ca.gov. Licensee was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care.
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SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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: DORLUS FAMILY CHILD CARE
FACILITY NUMBER: 198400263
VISIT DATE: 12/22/2021
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Senate Bill 792: this bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the visit.

Based on this information, the following deficiencies on the attached LIC 809D 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.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.


Exit interview was conducted and report was reviewed with the Licensee (or facility representative), Jessieika Dorlus.


Report Ends - Page 5 of 5
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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Document Has Been Signed on 12/22/2021 01:11 PM - It Cannot Be Edited


Created By: Katrina Chicote On 12/22/2021 at 12:34 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: DORLUS FAMILY CHILD CARE
FACILITY NUMBER: 198400263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021

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 interview at 11:00 AM, LPA did not observe a disaster drill log available during today's inspection. Per Licensee, she has not conducted a disaster drill log within the last 6 months. This poses a potential health, safety, and personal rights risk to children in care.
POC Due Date: 01/24/2022
Plan of Correction
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Licensee states she will conduct emergency drill within the next month and provide proof of log to LPA via email by POC date. LPA provided an example of drill log at time of inspection.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interiew at 12:01 PM, LPA did not observe emergency ID information for C1 at time of inspection per Licensee authorized representative has documents and will bring them in.
POC Due Date: 01/24/2022
Plan of Correction
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Licensee states she will obtain Emergency ID cards for C1 and provide copy to LPA via email by POC date.
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:Trevino Cochran
LICENSING EVALUATOR NAME:Katrina Chicote
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


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Document Has Been Signed on 12/22/2021 01:11 PM - It Cannot Be Edited


Created By: Katrina Chicote On 12/22/2021 at 12:37 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: DORLUS FAMILY CHILD CARE
FACILITY NUMBER: 198400263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(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
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Based on record review at 12:00 PM, LPA did not observe children to have immunization records available for children at time of inspection.
POC Due Date: 01/24/2022
Plan of Correction
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Licensee states she will provide proof of obtaining immunization records from children via email by POC date.
Type B
Section Cited
CCR
102517(8)(g)
Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview at 12:00 PM, LPA did not observe current facility roster at today's inspection; and per Licensee, she states that she does not have a current one at this time. This poses a potential health, safety, and personal rights risk to children in care.
POC Due Date: 01/24/2022
Plan of Correction
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Licensee sttes she will provide proof of completed current roster via email by POC date.
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:Trevino Cochran
LICENSING EVALUATOR NAME:Katrina Chicote
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


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