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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700285
Report Date: 07/07/2022
Date Signed: 07/07/2022 12:30:18 PM


Document Has Been Signed on 07/07/2022 12:30 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:SMITH FAMILY CHILD CAREFACILITY NUMBER:
367700285
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
07/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Applicant, Peggy SmithTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Maddox conducted a Pre-Licensing inspection and met with Peggy Smith, Applicant, who guided analyst on a tour of the facility for a Relocation inspection. This is a single story home with 3 bedrooms, 2 bathrooms, kitchen/dining area, living room; garage, and backyard. Family members residing in the home include (2 adults, applicant and 1 male adult resident). Days/hours of operation will be 7 days a week from 6am to 11:30 pm.

Physical Plant: The following areas are designated for child care: Dining area, living room, bathroom, 2 bedrooms and the backyard. Off limit areas are garage, Applicant's bedroom, and the laundry room. Home is clean and orderly, fireplace is inaccessible (applicant will place a child safety latch on glass doors to fire place), age appropriate toys and play equipment, working smoke detector and carbon monoxide detector, operable Fire Extinguisher (2A10BC), no one smokes in the home. There is a designated area for ill child(ren) as necessary (office/bedroom), there are/are no weapon/firearms in the home. There is a working telephone on the premises. Hazardous items are inaccessible to children (located in an upper cabinet in the laundry room). Medicines are inaccessible to children (located in Applicants bedroom which is kept locked while day care children are present).

Kitchen: The following are inaccessible - Sharp utensils, lighter and/or matches, open bottles of alcohol are inaccessible.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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: SMITH FAMILY CHILD CARE
FACILITY NUMBER: 367700285
VISIT DATE: 07/07/2022
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The bathroom was toured and there were no hazardous items accessible. Bathtub and shower are free of hazards.

The outdoor play area was toured and there are no bodies of water observed. The yard is safe for children (inaccessible – lawnmower, gardening tools, poisonous plants, thorn trees, cactus, pets). The entire yard is fenced. Children must be supervised while playing outdoors. LPA advised Applicant to cover any tree stumps with jagged edges to prevent any injuries to children.

Advisory/Other: First Aid kit was observed with supplies readily available. CPR/First Aid expire 11/27/23. The electrical outlets are covered. Children will nap on futons, applicant states she will purchase mats or at a latter date. Electrical outlet are inaccessible. Windows are free from cracks, there were no mini-blinds in place during this inspection.

Documents Provided and or Discussed: The following were observed/discussed and or provided: Seat Belt Safety, Updated Safe Sleep Regulations including from LIC 9227 and Safe Sleep log. forms required for children file (LIC311D), Notification of Parents' Rights (PUB394), Roster (LIC9040), Staffing and Ratio (capacity limitations handout provided), Emergency and Disaster Information (LIC610, LIC9148), Lead Flyer Requirement, liability insurance (LIC182) must have signed form on file if no liability insurance.

Applicant 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.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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: SMITH FAMILY CHILD CARE
FACILITY NUMBER: 367700285
VISIT DATE: 07/07/2022
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Applicant was informed to check 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 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 following was discussed with the Applicant:

Mandatory Reporter training and the renewal every 2 years (applicants Mandated Reporter training is current exp 12/15/23), forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter were reviewed; Applicant were reminded that 100% supervision is required at all times to children in care; Applicant was informed 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; Regulation prohibits the smoking of any kind during the operation of the day care.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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: SMITH FAMILY CHILD CARE
FACILITY NUMBER: 367700285
VISIT DATE: 07/07/2022
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Applicant was advised of the requirement to report Unusual Incidents. A report shall be made to the department by telephone or fax, or email (UnusualIncidentReport@dss.ca.gov) by the next business day. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events. Applicant was informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department.

The Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 moApplicant was advised of the requirement to report Unusual Incidents. A report shall be made to the department by telephone or fax, or email (UnusualIncidentReport@dss.ca.gov) by the next business day. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events. Applicant was informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department.

The Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenevnths & Applicant must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: SMITH FAMILY CHILD CARE
FACILITY NUMBER: 367700285
VISIT DATE: 07/07/2022
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Exit interview conducted, copy of this report was read and provided to Peggy Smith, Applicant, on this date. Applicant was informed during this inspection she will need to transfer her exemption, LPA provided form LIC 9188 - Criminal Record Exemption transfer request form and the website for Guardian. Applicant can also access Guardian through the following links.

You can check the link below for updated statues on your case: https://search.ccl.dss.ca.gov/BackgroundCheck

https://guardian.dss.ca.gov/Applicant

https://search.ccl.dss.ca.gov/BackgroundCheck

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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