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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400499
Report Date: 12/02/2021
Date Signed: 12/02/2021 03:01:12 PM

Document Has Been Signed on 12/02/2021 03:01 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:HAYES FAMILY CHILD CAREFACILITY NUMBER:
198400499
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/02/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Applicant, Tierrea HayesTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Katrina Chicote conducted a pre-licensing inspection today, 12/02/2021 at 11:45 AM at the above facility. LPA met with Tierrea Hayes, Applicant and guided LPA on a tour of the facility. People living in the home were discussed and all adults have criminal record clearance. The Applicant is requesting a Small Family Child Care Home license. Per Applicant, operation hours will be 24 hours/7 days a week. Applicant understands she cannot provide care for a child longer than 23 hours. Overnight care procedure was discussed with Applicant, and Applicant understands Title 22 Regulation requirements for overnight care. Applicant states that she will care for children 0-12 years of age.

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a single-story home that consists of two bedrooms, one bathroom, dining room, living room, kitchen, detached garage, and backyard.

Per Applicant, the children will have access to Living Room area as Main Day Care Space. Living Room area is located upon entry of the home and Bathroom 1 located down the hallway to the rear of the home. Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service, ventilation and heating. At 11:48 AM, LPA observed Main Day Care Space to have ceiling fan for ventilation and a small portable heater for heating in inaccessible area in Main Day Care Space . At 11:49 AM, LPA observed small tables and chairs with books and art supplies, cubbies with plastic dinosaur toys, blocks, legos, and other age appropriate toys available for children free of lose and sharp parts . At 11:50 AM, LPA observed Bathroom 1, that children will use, to have operable toilet and sink, hand-washing poster posted, adequate hand-washing supplies, floor to be free of hazards, and shampoos, detergents, and cleaning compounds to be placed in under cabinet sink with operable child safety lock at time of inspection. Per Applicant, children will have access to Kitchen area primarily for eating. At 11:51 AM, LPA observed Kitchen area to have operable child safety locks on all under cabinets and drawers at time of inspection. LPA observed knives, detergents, and cleaning compounds stored in a cabinet with child safety lock REPORT CONTINUES ON NEXT PAGE – 01 of 05
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 198400499
VISIT DATE: 12/02/2021
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making it inaccessible to children in care at time of inspection. The Applicant was advised that any poisons such as detergents, cleaning compounds, and medicines must be made inaccessible or stored somewhere with a key or combination lock.

Based on the Facility Sketch submitted, areas off limits to children are Bedroom 1, Bedroom 2, Laundry Room, and detached garage. At 12:15 PM, LPA observed operable baby gates at time of inspection making areas off limits to children in care. Applicant also states Bedrooms will also be locked during operating hours, LPA observed Bedroom doors to be locked at time of inspection. The Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary. Per Applicant, there are no pets, firearms, or weapons in the home, LPA did not observe pets, firearms or any weapons in the home at time of inspection.

Per Applicant, the children will use the side and front yard for outdoor play, which is accessible through front door. LPA observed outdoor play area has grass and adequate perimeter fencing through-out the yard. LPA observed wooden playhouse, dramatic play toys, small table and chairs, and other age appropriate toys free of loose and sharp parts available for the children in the backyard and all trees, shrubs, and plants are maintained at time of inspection.

At 11:45 AM, LPA observed the valve on the required 2A 10BC fire extinguisher indicates fully charged. At 11:46 AM, LPA observed dual smoke and carbon monoxide detectors are in operable condition at time of inspection. LPA observed First Aid kit is kept on a table in Main Day Care Space, First Aid kit was inventoried for necessary supplies. The Applicant has proof of immunization against influenza, pertussis, and measles readily available during today’s inspection. The Licensee has also taken the Mandated Reporter Training. Per Applicant, she has CPR First Aid Training certificate completed on 01/08/2021 but upon LPA review it was not Pediatric. Per Applicant she will obtain training for Pediatric First Aid CPR by 12/07/2021 and provide proof to LPA.
—Fire Extinguisher was purchase on: 11/13/2021
—Mandated Reporter AB1207 Completed: 01/18/2021

The Applicant states that they will provide food for children in care, LPA observed refrigerator for cleanliness and necessary supplies.
REPORT CONTINUES ON NEXT PAGE - 02 of 05
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 198400499
VISIT DATE: 12/02/2021
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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. Civil Penalties will be assessed if not in compliance.
· 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 Pediatric First Aid and CPR training, Immunizations (TDAP, MMR, Influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.
· Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
· The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked and batteries replaced as needed.
· Reporting Requirements: 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.
· 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 for a minimum of 3 years.
· 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.
· Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
· The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.
· Isolation for Ill children: When a child is ill he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home). Applicant states she will use space that is not being used by children at the time as isolation area.
· Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information. REPORT CONTINUES ON NEXT PAGE – 03 of 05
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 198400499
VISIT DATE: 12/02/2021
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· Immunization Requirement: H&S 1597.622: 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. The licensee and all adults working with children have proof of immunizations.

· Mandated Reporter Training: H&S 1596.8662: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com

Infant Care: Applicant states that they will care for infants. LPA advised the Applicant to sleep infants where they can be directly supervised at all times and advised against sleeping infants in a separate room. LPA provided the Applicant with a hard copy of PIN 20-24-CCP Recently Approved Safe Sleep Regulation in Effect, and LIC 9227.



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

LPA advised the Applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms:

CHILDREN FORMS/RECORDS - Children’s files must contain the following documents/information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), Consent/Verification for Nebulizer Care (LIC 9166), California School Immunization Record, Parent Notification for Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Acknowledgment of Receipt of Licensing Reports (LIC 9224).
REPORT CONTINUES ON NEXT PAGE – 04 of 05
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: HAYES FAMILY CHILD CARE
FACILITY NUMBER: 198400499
VISIT DATE: 12/02/2021
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FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records: As required in Title 22 Regulations 102416.1, Unusual incident/Injury Report (LIC 624B): Child Care Facility Roster (LIC 9040), Notice of Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108), Property Owner/Landlord Consent (LIC 9149), Property Owner/Landlord Notification Form (LIC 9149).

INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by Law to post the following:
Facility License (LIC 203), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parent’s Rights (PUB 394). A Notice of Site Visit (LIC 9213): Must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

OTHER INFORMATION AND FORMS PROVIDED:
· Capacity Handout for a Small Family Child Care Home and Large Family Child Care Home was provided.
· Handout for Lead poisoning

Per Applicant, there are no dual licenses at this address.

Based on the LPA’s observation, the following corrections need to be corrected prior to obtaining a small family child care license. Corrections are due by December 7, 2021.
- Applicant needs proof of completion of Pediatric First Aid/CPR.

A small family child care licensee will be granted upon receipt of proof of corrections for the above and upon review of Supervisor. Once licensed, the Applicant is required to comply with the terms and limitations stated on the license. Proof of corrections may be submitted via email by correction date.

Exit interview was conducted with Applicant Tierrea Hayes, who acknowledges receipt of report.
REPORT ENDS - PAGE 05 of 05
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC809 (FAS) - (06/04)
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