198400389-3-2-2023-54-CC-DGIS-CPJQV9-20230302112958

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400389
Report Date: 03/02/2023
Date Signed: 03/02/2023 11:30:17 AM

Document Has Been Signed on 03/02/2023 11:30 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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	HAWK FAMILY CHILD CARE		FACILITY NUMBER:	198400389
ADMINISTRATOR:	HAWK, EBONY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 603-9694
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90018
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 8	DATE:	03/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ebony Hawk, Licensee		TIME COMPLETED:	11:45 AM

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 Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 3/2/22 at 9:45 AM. LPA met with Ebony Hawk, Licensee who guided analysts on a tour of the facility. There were eight children and two adult present when LPA arrived. Facility capacity is in compliance for a large Family Child Care Home. This is a two-story home that consists of three bedrooms, 3.5 bathrooms, Living Room, Dining Room, Kitchen, Laundry Area, Front yard and backyard (fenced). Main care is provided in the dining room and backyard. Per Licensee, areas off limits to children and parents include: the bedrooms and three bathrooms on the second floor and the living room on the first floor made inaccessible with child safety gates. Hours of operation are Sunday-Saturday 23.5 hours. Food is provided by Licensee. Licensee was reminded if children bring food from home it must be labeled with the child’s name and properly stored or refrigerated. Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption. LPA discussed Guardian with licensee and provided information on how to access the website and utilize it to add adults to her facility. All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection: LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on 2/25/23. All documents observed on the parent board in the main care area. -------------------PAGE 1

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HAWK FAMILY CHILD CARE	FACILITY NUMBER: 198400389
	VISIT DATE: 03/02/2023

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
26
27
28
29
30
31
32

Smoke and carbon monoxide detectors in the main care area were tested and are operable. Fire extinguisher indicated fully charged and was serviced, 3/2022. LPA reminded licensee that fire extinguisher service is due this month. The home maintains telephone service via landline and cell phone. The home is observed to be clean and orderly. There are toys and other age appropriate material available for children. Floor heaters in main care area are not used. Stairs are made inaccessible using a safety gate. LPA observed that detergents, cleaning compounds and medication are stored in a closet, inaccessible to children. Licensee states that there are no poisons stored in the home. Isolation area for sick children waiting to be picked up is upstairs in the bedroom previously used as a nap room for infants, away from the other children. Per licensee upstairs nap room is currently being used as a storage due to the low number of infants. If licensee gets more infants, she will reopen that room. Per Licensee there are no firearms or weapons stored in the home.

The bathroom that children use is located adjacent to the main care area on the first floor and was observed to be clean and free of hazards.

Infant Care: Currently licensee cares for one infant, 12 months and up. LPA observed one play yard visible in the main care area. Napping equipment does not block entrances or exits. Play yard was observed to have standard flat matt with tightly fitted sheet. LPA did not observe loose object, bumpers, objects hanging, or objects attached to the play yard. Per licensee wet or soiled sheets are washed right away or stored in a bag to be taken home by parents. LPA reminded licensee of the Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months and 15-minute sleep check documentation for infants 0-24 months. Licensee states the following a sleep supervision plan for infants: Infant naps in the main care area where they can be supervised at all times.

Overnight Care: Licensee currently does not have any overnight children. Licensee is aware that they must remain wake while children are awake. If children sleep in separate area from licensee, the door must remain open. If licensee cannot hear children when they wake up, video or audio device can be used.

Currently, children are not using the backyard for outdoor play. Due to the recent wind and rain, licensee has put toys and material away and has to ensure that the yard is safe before the children go out again. Before allowing the children to play outdoors Licensee will inform LPA. The outdoor play area was observed to be fenced. There are no pools or spas, or other bodies of water.

-----------------------PAGE 2

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HAWK FAMILY CHILD CARE	FACILITY NUMBER: 198400389
	VISIT DATE: 03/02/2023

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
26
27
28
29
30
31
32

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months). LPA observed infant in care is missing 15 minute sleep check. LIC 627 discussed..

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 immunization 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. LPA observed that S2 does not have a file for review.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Based on LPA observations and records review, the following deficiencies listed on the attached LIC 809D (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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address

----------------------PAGE 3

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

Page: 3 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HAWK FAMILY CHILD CARE	FACILITY NUMBER: 198400389
	VISIT DATE: 03/02/2023

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
26
27
28
29
30
31
32

information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

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 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.

Exit interview conducted and report was reviewed with the Licensee, Ebony Hawk.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 03/02/2023 11:30 AM - It Cannot Be Edited

Created By: Denise Gibbs On 03/02/2023 at 11:10 AM

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: HAWK FAMILY CHILD CARE	FACILITY NUMBER: 198400389
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416.1(d)

Personnel Records

(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. MISSING FILE FOR S2, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Licensee agrees to email all documents requires for an assistants file to LPA by POC date 3/10/23.

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

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, the licensee did not comply with the section cited above in one infant file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Licensee agreed to begin 15 minute sleep checks for C5 and email a full week of documented checks to LPA by POC date 3/10/23.

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:

Karen Chambers

LICENSING EVALUATOR NAME:

Denise Gibbs

LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

Page: 7 of 7