376101439-4-7-2023-51-CC-KLAE-CQNMBZ-20230407092845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376101439
Report Date: 04/07/2023
Date Signed: 04/07/2023 09:28:57 AM

Document Has Been Signed on 04/07/2023 09:28 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	POLIS, RAIDAI & BUTRUS, VIRJINYA FAMILY CHILD CARE		FACILITY NUMBER:	376101439
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	04/07/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Raidai Polis & Virginya Butrus		TIME COMPLETED:	09:40 AM

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 4/7/23 at 8:05 AM, Licensing Program Analyst (LPA) Keturah Lane, conducted an announced Pre-Licensing inspection for relocation with the applicants. Upon arrival, LPA met with applicants Raida Polis and Virjinya Butrus and also present were Bashar Butrus, Mary Butrus and applicant’s minor daughter. The one-story home was toured and inspected to ensure an environment safe for the care and supervision of children. The fire extinguisher and carbon monoxide/smoke detector combo meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children. There is a swimming pool in the backyard that has a picket fence on one side only that is 3ft 10 inches high. The fence does not completely surround the pool. The picket fence wobbles back and forth when pulled on and is stationed into the concrete. The picket fence gate swings away from the pool but does not close on its own and is not self-latching. The horizontal beams of the picket fence are less than 45 inches apart and the openings between pickets are no more than 4 inches. There are two windows that lead to the pull. One is in a room the children use (living room #2) and the other is in an off-limits room (bedroom #2). There are alarms on the windows. There is a sliding glass door in off-limits bedroom 3 that leads directly to the pool. These rooms are inaccessible through door locks only. Based upon LPA observations (photos and video were taken by LPA) this pool does not meet Title 22 regulations. Applicants state that there are no weapons in the home. CPR and First Aid expire in 9/2023 for Raidai Polis and 2/8/25 for Virjinya Butrus. Preventative health practices course was completed on 3/3/23 for both applicants, which includes lead poison prevention training. Mandated reporter training was completed by Virjinya Butrus on 3/19/23 and Raidai Polis is exempt as she speaks Arabic. Staff immunization requirements were met. Required documents have been posted. Applicants own the home. The applicants have toys and equipment available. (continued on LIC809-C...)

SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: POLIS, RAIDAI & BUTRUS, VIRJINYA FAMILY CHILD CARE	FACILITY NUMBER: 376101439
	VISIT DATE: 04/07/2023

NARRATIVE

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Applicants were 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.

Applicants will be using the following rooms for childcare: living room, living room #2, kitchen and bathroom #1. Off limits areas include: bedroom #1, bedroom #2 and bedroom #3 which includes a smaller bathroom #2 and are inaccessible through the use of door-knob covers and door locks. The garage will also be off limits and is kept inaccessible through the use of a door knob cover. The backyard and front yards are off-limits. Applicants stated they will take the children to a nearby park for outdoor activities and understand that visual supervision is required at all times for outdoor activities at the park.

LPA provided packet with information regarding safe sleep, LIC311D Forms records to keep in your family child care homes, children’s forms/records, facility forms/records and information to be posted. LPA advised applicants to review the material and when LPA comes back once pool corrections are made – the material will be further reviewed together if there are any questions.

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.

(continued on LIC809-C...)

SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: POLIS, RAIDAI & BUTRUS, VIRJINYA FAMILY CHILD CARE	FACILITY NUMBER: 376101439
	VISIT DATE: 04/07/2023

NARRATIVE

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The following corrections are needed prior to the issuance of the license:
1. Swimming pool must meet Title 22 requirements
a. Fence must be in good repair and completely surround the pool
b. Fence is at least 5 feet high
c. No window or door provides direct access to the pool
d. Gates swing away from the pool, self-close and are self-latching
e. Self-latching device should be located no more than 6 inches from the top of the gate

Once all corrections are made and proof is sent to licensing a license for 8 children may be granted. Applicant understands that proof of corrections must be submitted to Licensing within 30 days or the application may be denied. Applicant agreed to comply with all regulations and laws governing family child-care homes.

Exit interview conducted and report was reviewed with co-applicants Raidai Polis and Virjinya Butrus.

SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC809 (FAS) - (06/04)

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