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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400805
Report Date: 05/18/2023
Date Signed: 05/18/2023 11:22:25 AM

Document Has Been Signed on 05/18/2023 11:22 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:PETERSON FAMILY CHILD CAREFACILITY NUMBER:
198400805
ADMINISTRATOR:PETERSON, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 610-5722
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Michelle Peterson, ApplicantTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Denise Gibbs conducted a pre-licensing inspection on 5/18/23 at 10:00AM. LPA met with Michelle Peterson, Applicant who guided analyst on a tour of the facility. Applicant is requesting a large family childcare home license. Per applicant, operation hours will be Monday - Sunday, 23.5 hours. 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 one-story home that consists of three bedrooms, two bathrooms, Open concept dining room, living room, kitchen, front yard (not fenced), backyard (fenced) and detached garage. Main care areas include, two bedrooms, one bathroom and back yard. Children will have access to the living room but it will not be main care. Off limit areas include, primary bedroom with bathroom and detached garage. Applicant states that the doors will remain locked during the hours of operation. The applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Areas that will be used by children were inspected for safety, comfort, cleanliness. LPA observed toys and materials age appropriate for children in the main care areas. LPA observed operable telephone service via cell phone/landline. Facility has ventilation and heating via central air. Detergents, cleaning compounds, medicines and hazardous items that can pose a danger to children are made inaccessible in a cabinet in the off limits kitchen above the refrigerator. Children will nap on mats. Isolation area for a sick child waiting to be picked up will be in the living room, away from other children.

Per applicant there is one small dog in the home and he will remain in the backyard and has a crate he can be put in if needed. There are no firearms or weapons stored in the home.



LPA observed that the Applicant has a 2A10 BC fire extinguisher in the home, purchased on 3/2023. Dual smoke and carbon monoxide detector located in the hallway was tested and is operable.--------------PAGE 1
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: PETERSON FAMILY CHILD CARE
FACILITY NUMBER: 198400805
VISIT DATE: 05/18/2023
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LPA discussed the safe sleep regulations with applicant 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 applicant 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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 reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Entrance Checklist was provided to the applicant.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

A large family childcare license will be granted upon Licensing Program Manager (LPM) Approval. A fire clearance was granted on 4/25/23. Once licensed, the applicant is required to comply with the terms and limitations stated on the license.



Exit interview conducted and report was reviewed with the applicant, Michelle Peterson.

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SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: PETERSON FAMILY CHILD CARE
FACILITY NUMBER: 198400805
VISIT DATE: 05/18/2023
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The applicant states that she will provide food for children in care. LPA reminded applicant that any food brought from the children’s homes shall be labeled with child’s name and properly stored or refrigerated. Applicant was reminded that they shall be present in the home and ensure children are supervised at all times. If applicant temporarily leaves the home they must ensure a substitute adult with required trainings and documents must be to supervise the children in their absence.

The applicant has completed the required Health and Safety Training, Pediatric First Aid and CPR which expires 2024 and Mandated Reporter Training. Applicant has proof of immunization against measles, pertussis and flu declination on file. There are first aid supplies available.

Infant Care: Applicant states that they will care for infants 0-24 months old. LPA observed one play yard in storage. Applicant was reminded that equipment should not block entrances or exits. Infant mattresses must be firm with tightly fitted sheets. Play yard should not have loose object, bumpers, objects hanging, or objects attached. Each infant must have their own crib/ play yard and bedding. Bedding will be washed once a week. LPA informed applicant of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP.

Overnight Care: Applicant is aware that they must remain wake while children are awake. If children sleep in separate area from applicant, the door must remain open. If applicant cannot hear children when they wake up, video or audio device can be used.

Outdoor play area is located in the backyard. LPA observed that the backyard is fenced and free of hazards. The outdoor play area has toys and age appropriate material for children. LPA did not observe any pools, spas or bodies of water on the premises. LPA observed stairs that lead to the detached garage. Stairs are made inaccessible with a gate. Garage will remain locked.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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. ------------PAGE 2

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
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