334846371-4-24-2023-09-CC-ASHA-CR7QFA-20230424120733

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334846371
Report Date: 04/24/2023
Date Signed: 04/24/2023 12:07:43 PM

Document Has Been Signed on 04/24/2023 12:07 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	KELLY FAMILY CHILD CARE		FACILITY NUMBER:	334846371
ADMINISTRATOR:	KELLY, SARAH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 522-5964
CITY:	BEAUMONT	STATE: CA	ZIP CODE:	92223
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	04/24/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Sarah Kelly		TIME COMPLETED:	12:20 PM

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

On date and time listed, Licensing Program Analyst (LPA) Aman Sharma arrived at the facility to conduct a pre-licensing inspection. Present during this inspection was Applicant and her spouse. LPA toured the home, inside and out and the following was observed and/or discussed:

Normal days and hours of operation: Monday- Friday 6am-6pm
OFF-LIMIT AREAS INCLUDE: First bedroom, second bedroom, master bedroom, master bath, including the shower and closet, the laundry and the garage.
· Smoke detector, carbon monoxide detector and fire extinguisher were appropriate and in working order.
· All hazardous items are inaccessible
· Storage of poisons/toxins are inaccessible to children and locked
· Weapons are not present according to Title 22. Applicant understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Verification of control of property is on file.
· Facility Sketch and Emergency Disaster Plan are posted
· Mandated Reporter Training completed on: 03-20-2023
· Pediatric CPR and First Aid Card – expire on: 03-24-2025
· Health & Safety Certificate - completed on: 03-21-2023

· No bodies of water on property 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 were observed to be readily available.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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 3

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KELLY FAMILY CHILD CARE	FACILITY NUMBER: 334846371
	VISIT DATE: 04/24/2023

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

· There are no toxic plants observed at this time
· The Applicant was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· Resident and/or staff records reviewed indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· The Applicant can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

The following was discussed with the applicant(s):
- 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.
- Pre-Licensing Visit Packet was provided
- Applicant understands failure to meet posting requirements will result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills are to be conducted every six months
- Responsibilities of being a mandated reporter must be renewed every 2 years
- Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must be on file with the licensing office at all times
- Baby walkers, bouncy seats, exer-saucers and other similar items are prohibited
- 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.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KELLY FAMILY CHILD CARE	FACILITY NUMBER: 334846371
	VISIT DATE: 04/24/2023

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

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

- 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.

- 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

The application for a Large Family Child Care Home will be submitted for approval with a maximum capacity of 12, or 14 with parent notification. Applicant does not have any corrections pending at this time.

Applicant, Sarah Kelly confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the Applicant, Sarah Kelly..

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3