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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845009
Report Date: 10/11/2022
Date Signed: 10/12/2022 08:22:29 AM

Document Has Been Signed on 10/12/2022 08:22 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
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:FORD FAMILY CHILD CAREFACILITY NUMBER:
334845009
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Serene Ford TIME COMPLETED:
04:10 PM
NARRATIVE
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On October 11, 2022 at 1:12 PM, Licensing Program Analyst (LPA) Anastasia Flores arrived at the facility to conduct an annual inspection as part of a compliance review. At 1:24 PM, 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: 7 days a week from 5:00 AM to 4:00 AM

· Off-limit areas include: second floor, garage, living room, kitchen and back hallway

· The facility is licensed to have no more than 8 children as a small FCCH and is operating within the licensed capacity and appropriate ratios.


· Appropriate supervision provided during this inspection

· A working telephone is present, and the current phone number is on file

· A fully charged fire extinguisher (2A:10BC) was observed. A smoke detector and carbon monoxide detector were present and not tested by the Licensee during this inspection due to children sleeping. LPA advised Licensee to check it with next emergency drill which is going to be done this week.

· Fireplace is properly screened to prevent access by children

· All hazardous items are stored inaccessible to children in the garage

· Toxins are locked in the garage and in hall cabinet

· Weapons are not present. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

· Stairs are barricaded

· Clean, safe and age appropriate toys licensee was informed the outside toys need to be cleaned prior to using again.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Anastasia Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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 11
Document Has Been Signed on 10/12/2022 08:22 AM - It Cannot Be Edited


Created By: Anastasia Flores On 10/11/2022 at 03:12 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: FORD FAMILY CHILD CARE
FACILITY NUMBER: 334845009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in staff #2 (volunteer) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2022
Plan of Correction
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Licensee will not allow Staff #2 to return to the facility until background clearance has been completed and cleared.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Anastasia Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 10/12/2022 08:22 AM - It Cannot Be Edited


Created By: Anastasia Flores On 10/11/2022 at 03:12 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: FORD FAMILY CHILD CARE
FACILITY NUMBER: 334845009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on(observation & interview, the licensee did not comply with the section cited above in backyard toys need to be clearned and childrens area has broken toys that need to be removed. The back of children's play room was stacked with items used for children in an unsafe manner. It was not blocked off to be inaccessible to children in care. [which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2022
Plan of Correction
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Licensee will clean up the area and send a photo to LPA Flores via email by 11/11/22
Section Cited
Operation of A Family Child Care Home
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Anastasia Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 10/12/2022 08:22 AM - It Cannot Be Edited


Created By: Anastasia Flores On 10/11/2022 at 03:12 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: FORD FAMILY CHILD CARE
FACILITY NUMBER: 334845009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022

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 record review and interview, the licensee did not comply with the section cited above in one of three staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2022
Plan of Correction
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licensee will obtain immunization records from staff #2 (volunteer) and create a file, Licensee will send LPA Flores via email a copy of the immunization records for staff #2 (volunteer)
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Anastasia Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022


LIC809 (FAS) - (06/04)
Page: 4 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: FORD FAMILY CHILD CARE
FACILITY NUMBER: 334845009
VISIT DATE: 10/11/2022
NARRATIVE
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·Current roster on file

· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted

· Documentation of fire and disaster drills on file – Last drill conducted on April of 2022

· 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.

· Verification of control of property on file in main office (rental agreement)

· Children’s records are complete

· Employee’s records are not complete

· Mandated Reporter Training completed on 07/06/2021 expires on 7/2023

· Pediatric CPR and First Aid Card expires on 07/06/2024

· Health & Safety Certificate - completed on 11/07/2017


· Resident and/or staff records were reviewed and there is one adult volunteer without the required caregiver background check and have not received all required clearances and/or exemptions.

The licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.
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

The Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Anastasia Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: FORD FAMILY CHILD CARE
FACILITY NUMBER: 334845009
VISIT DATE: 10/11/2022
NARRATIVE
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The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.ca.gov
LPA discussed the safe sleep regulations with licensee Serene Ford, 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.

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.

Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.


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.
A civil penalty has been assessed during this inspection, payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. You will receive an invoice in the mail. Do not send money until you receive your invoice. Do not send cash.; See LIC809-D for cited deficiencies

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

An exit interview was conducted, and a copy of this report, LIc809D’s, was reviewed with the licensee, Serene Ford. Appeal rights were discussed and provided during the exit interview.


A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Anastasia Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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