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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334814595
Report Date: 09/20/2023
Date Signed: 09/20/2023 03:48:58 PM

Document Has Been Signed on 09/20/2023 03:48 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:ALLEN FAMILY CHILD CARE HOMEFACILITY NUMBER:
334814595
ADMINISTRATOR:ALLEN, SANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 849-3116
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Facility Representative Auvianna MaysTIME COMPLETED:
04:00 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Perla Ordones arrived at the facility to conduct a required/annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:

Normal days and hours of operation are: Monday – Friday; 04:30AM – 09:00PM.

OFF-LIMIT AREAS INCLUDE: Garage, Master bedroom, Bedroom 3.

The facility is operating within the licensed capacity and appropriate ratios.

· Appropriate supervision provided during this inspection.
· A working telephone is present and current number on file.
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· Fireplace is properly screened to prevent access by children.
· All hazardous items are stored inaccessible to children.
· Toxins are locked.
· Weapons are not present. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Facility is a one story home.
· Verification of control of property on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted.
· Mandated Reporter Training completed on 08/02/2023.
· Pediatric CPR and First Aid Card expire on 07/2025.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Perla Ordones
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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 8
Document Has Been Signed on 09/20/2023 03:48 PM - It Cannot Be Edited


Created By: Perla Ordones On 09/20/2023 at 02:58 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: ALLEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 334814595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as the last firedrill, conducted 01/20/2023, was not conducted within the required six month time frame which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Licensee agrees to conduct a firedrill and submit proof of the firedrill to Community Care Licensing (CCL) by the end of the business day on the Plan of Correction (POC) due date of 10/04/2023.

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:Kimberly Williams
LICENSING EVALUATOR NAME:Perla Ordones
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2023 03:48 PM - It Cannot Be Edited


Created By: Perla Ordones On 09/20/2023 at 02:58 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: ALLEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 334814595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as S2 was missing proof of the Tuberculosis vaccine and Pertussis vaccine while S3 was missing proof of the MMR vaccine which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Licensee agrees to obtain proof of the required immunizations for both S2 and S3. Licensee agrees to submit proof to Community Care Licensing (CCL) by the end of the business day on the Plan of Correction (POC) due date of 10/04/2023.
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as both C1 and C3 were missing proof of the AFFIDAVIT REGARDING LIABILITY INSURANCE FOR FAMILY CHILD CARE HOME (LIC282) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Licensee agrees to have C1 and C3's authorized representatives sign the LIC282 and agrees to send proof to Community Care Licensing (CCL) by the end of the business day on the Plan of Correction (POC) due date of 10/04/2023.
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:Kimberly Williams
LICENSING EVALUATOR NAME:Perla Ordones
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2023 03:48 PM - It Cannot Be Edited


Created By: Perla Ordones On 09/20/2023 at 03:09 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: ALLEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 334814595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(d)(1)
(d) In any case in which the licensee cares for an additional child pursuant to Section 102416.5(b) for a Small Family Child Care Home or Section 102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child's record, proof of parent notification that the facility is caring for an additional child as required in Section 102416.5(h).
(1) The licensee shall maintain a completed and signed LIC 9150 (Rev. 8/14) Parental Notification Additional Children in Care, which is incorporated by reference, for this purpose.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as both C1 and C3 were missing proof of the PARENT NOTIFICATION ADDITIONAL CHILDREN IN CARE (LIC9150) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Licensee agrees to have C1 and C3's authorized representatives sign the LIC9150 and agrees to send proof to Community Care Licensing (CCL) by the end of the business day on the Plan of Correction (POC) due date of 10/04/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberly Williams
LICENSING EVALUATOR NAME:Perla Ordones
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


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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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: ALLEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 334814595
VISIT DATE: 09/20/2023
NARRATIVE
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· Health & Safety Certificate – completed.
· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age-appropriate toys. During the facility tour, LPA observed a trampoline on the premises. The trampoline and its surrounding cover appear to be in good repair with no tears or exposed springs. LPA advised Licensee to speak to daycare children’s authorized representatives in order to gain consent before use of the trampoline by daycare children. The licensee agrees to only use the trampoline in accordance with the manufacturer’s guidelines and will provide adequate supervision to all children in care.
· Current roster on file.
· Documentation of fire and disaster drills on file – Last drill conducted on 01/20/2023. Regulations state that fire and disaster drills have to be conducted every six months which the licensee has not followed. LPA brought this to the attention of the Licensee who stated that she would correct the oversight immediately in order to go back into compliance.
· Children’s records are not complete. During record review, LPA observed that C1 and C3 were missing proof of the LIC282 as well as the LIC9150. LPA brought this to the attention of the Licensee who stated she would have authorized representatives fill out the forms as soon as possible.
· Employee’s records are not complete. During record review, LPA observed that S2 and S3 were missing proof of immunizations. S2 was missing proof of the Tuberculosis vaccine and Pertussis vaccine while S3 was missing proof of the MMR vaccine. LPA brought this to the attention of the Licensee who stated that both employees would submit proof of immunizations as soon as possible.

· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

· Resident and/or staff records reviewed on 09/20/2023 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Perla Ordones
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: ALLEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 334814595
VISIT DATE: 09/20/2023
NARRATIVE
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· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

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-andresources/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.

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: https://www.ada.gov/resources/child-care-centers/

Licensee 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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Perla Ordones
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: ALLEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 334814595
VISIT DATE: 09/20/2023
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

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.

The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

See LIC809-D for cited deficiencies.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

During the exit interview, the LICENSEE Sandra Allen, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the Licensee Sandra Allen.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Perla Ordones
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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