367700179-4-5-2022-12-CC-KZIS-CD7QRK-20220405122403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 367700179
Report Date: 04/05/2022
Date Signed: 04/05/2022 12:24:24 PM

Document Has Been Signed on 04/05/2022 12:24 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	WILLIAMS FAMILY CHILD CARE		FACILITY NUMBER:	367700179
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 5	CENSUS: 0	DATE:	04/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Licensee, Jackie Williams		TIME COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Zirbes met with Licensee, Jackie Williams, who guided analyst on a tour of the facility for the One Year Required inspection. This is a one story three bedrooms, two bathroom home with kitchen/dining, living area, and detached garage. There are no pool/spa or body of water on the premises. Family members residing in the home include licensee, and her three children aged 5, 8, 10. . Upon arrival LPA observed zero children in care. Current days and hours of operation are Monday thru Sunday, 24 hours a day. Physical Plant: Child care is provided in the living area (left of entrance), the family room, hallway bathroom, and backyard. Off limit areas include all bedrooms, kitchen, dining room, and the detached garage. The off limits areas were made inaccessible via child safety gates and child safety door knobs covers and key locks on the master bedroom door. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (locked closet) medicines (locked closet) and hazardous items (locked closet) that can pose a danger to children. Fire/earthquake drills was last completed in January 2022. Documentation is maintained and up to date Safe and age appropriate toys, play equipment and materials. The smoke detector and carbon monoxide detector, Fire Extinguisher (2A10BC) are in operable condition. Per Licensee no one smokes in the home. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment were observed on the premises. The family room dining room is the designated area for ill children in the child care. There are age appropriate napping equipment, (cotes, play yard, and crib). Report continued on page two

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 367700179
	VISIT DATE: 04/05/2022

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Per Licensee, there are no weapons or firearms on the premise. In addition, LPA did not observe any weapons in the home. The home has a fireplace in the child care room, which was surrounded by a fire place gate and a shelf. Home has central AC and heat.

Bathroom: Shower/tub free of hazards. The following are inaccessible: Sharp items, mouthwash, shampoo, razor, nail polish. Toilet and faucet are clean and operable.

Outdoor: The backyard is completely fenced. There was one dog present during this inspection. Per Licensee the family is dog sitting and the dog is not normally present at the child care. The back yard was equipped with a trampoline and three swings. The trampoline and swings were placed on grass. LPA and Licensee discussed active supervision and safety when the trampoline is being used by the children.

Advisory/Other: First Aid kit was observed with supplies readily available. CPR/First Aid expires 8/29/2022 and Mandated Reporter expires 10/20/2022 . Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/play equipment were observed on the premises. There are no window cords accessible to children.

Review of records to be maintained: LPA reviewed with licensee 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. LPA reviewed five child files, and the Licensees file during this inspection. Files were complete during this inspection.

Documents Provided and or Discussed: Fire Drill Log, Roster, Postings, Safe Sleep, COVID-19 posters. Licensee stated currently she does have child care insurance.

The following were observed/discussed and or provided: Seat Belt Safety, Safe Sleep poster observed – PIN 19-02-CCP, forms required for children file (LIC311D), Notification of Parents' Rights (PUB394), Roster (LIC9040), License, Staffing and Ratio (capacity limitations handout provided), Emergency and Disaster Information (LIC610A, LIC9148), Lead Flyer Requirement, liability insurance (LIC282) must have signed form on file if no liability insurance. Report continued on page three

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 367700179
	VISIT DATE: 04/05/2022

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All adults living/residing in the home are fingerprint cleared and associated

The following was discussed with the licensee:

Mandatory Forms for the children’s files and provider’s files, Requirements for fire drills, earthquake drills, and documentation for both. Role and responsibilities of being a mandated reporter.

Licensee reminded that 100% supervision is required at all times to children in care. Licensee was made aware that it is he/her responsibility to know the regulations as well as anyone who assists in providing care. Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified

The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers, and any other items that fall into that category.

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.

Report continued on page four

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 367700179
	VISIT DATE: 04/05/2022

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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-and-resources/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.

·On January 1, 2018, or before March 30, 2018, a person who is a licensed childcare provider, administrator, or employee of a licensed child day care facility shall complete the online mandated reporter training and shall complete renewal mandated reporter training every two years. @www.mandatereporterca.com.

**Senate Bill AB 633 - Child Care Facilities: Parent Notification Requirements
Summary: This bill amends Health and Safety Code (HSC) sections 1596.859, 1596.8595, 1596.8895, and 1597.05 to improve the transparency of licensing records and to ensure that parents/guardians using a licensed childcare facility are aware of situations that present the greatest danger to children.

§1597.622 Employees or volunteers at family day care home; immunization requirements; records; exemptions (1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year

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. Per Licensee IMS is not being provided at this time.
Report continued on page five

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 367700179
	VISIT DATE: 04/05/2022

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Licensee advised visit www.shotsforschool.org for Immunization information.

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

There is an on-Duty Worker/Officer is available to answer any questions and concerns at
(661) 202-3318. Department hours of operation not including state holidays are Monday - Friday from 8:00am - 5:00pm

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/inspection-process.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee Jackie Williams.

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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