406216190-10-26-2021-17-CC-FVEZ-C86PAK-20211026110853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 406216190
Report Date: 10/26/2021
Date Signed: 10/26/2021 11:09:06 AM

Document Has Been Signed on 10/26/2021 11:09 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	TESFAZGY FCC AKA LITTLE WORLD CHILD CARE		FACILITY NUMBER:	406216190
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	10/26/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Milen Tesgazgy		TIME COMPLETED:	11:15 AM

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On 10/26/2021 at 8:30 AM, Licensing Program Analyst (LPA) Francisca Velazquez conducted an announced pre-licensing inspection of the facility. Prior to entering the facility, LPA conducted a COVID-19 pre-screening questionnaire and based on Applicant’s responses it was determined that the home is safe and free of any COVID-19 exposures. LPA met with Applicant, Milen Tesfazgy and explained the purpose of the Inspection. During this inspection, there were no children present at the facility.

LPA conducted the physical plant tour of the home. During this tour the following was noted:

Applicant applied for a Small Family Child Care License on 09/15/2021. Family members residing in the home are three (3) adults and two (2) underage children. All adults in the home are fingerprint cleared. Per Applicant, the operating days and hours of the day care will be Monday through Sunday for 24 hours. Applicant states she wants to care for children from birth through 12 years of age.

All areas identified on the facility sketch were inspected. This is a single story home which consists of five (5) bedrooms, four (4) bathrooms, one (1) living rooms, day care room, kitchen, dining room, garage and fenced backyard. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. LPA observed the designated day care areas to be safe with age appropriate toys, games etc. The back yard is enclosed with wooden fence. There are no bodies of water observed. CONT 809-C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: TESFAZGY FCC AKA LITTLE WORLD CHILD CARE	FACILITY NUMBER: 406216190
	VISIT DATE: 10/26/2021

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Off limit areas include: (4) bedrooms, three (3) bathrooms, living room, kitchen, dining room and garage and part of the back yard are off-limits and inaccessible to children in care. All areas are off limits by a door with safety latch. This door leads to the part of the home that is off-limits and inaccessible to children in care.

Areas used by children include: one (1) day care room, one (1) bedroom, one (1) bathroom and part of enclosed back yard. There are age appropriate toys and napping equipment on the premises. Knives are stored in the kitchen that is inaccessible to children in care. The required fire extinguisher 2A10BC was serviced on 06/17/2021. LPA reminded Applicant that fire extinguisher needs to be purchased or serviced annually. LPA observed a smoke detector and carbon monoxide detector in the day care area that were tested at 9:22 AM and were both functioning at the time of the visit. Applicant stated that parents will be entering the facility through the side of the home which leads right into the day care room. Per Applicant, there are no guns nor ammunition in the home. First Aid and emergency kits are available. The Applicant completed the Orientation on 08/10/2021. The Applicant has current Pediatric First Aid and CPR which expires 08/21/23. Applicant completed Preventative Health Training on 08/19/2021. Applicant completed the Mandated Reporter Training on 07/17/2021. Applicant was reminded to update her Mandated Reporter certificate every two (2) years. Applicant has proof of immunization per SB 792 against influenza, pertussis, and measles.

The following was discussed with the applicant:

· Individuals who are 18 years of age or older living in the home or working in the home, must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain the Criminal Record Background Check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

CONT 809-C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: TESFAZGY FCC AKA LITTLE WORLD CHILD CARE	FACILITY NUMBER: 406216190
	VISIT DATE: 10/26/2021

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In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification, TB clearance, immunization's, and a valid criminal record clearance associated to the facility license.

· A current roster of children enrolled must be available for review and maintained for a period of three years, even after children are no longer attending the facility.

· The fire extinguisher type 2A10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

· Changes in the home should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if applicant moved to another location/ home.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a Family Child Care Home, 24/7.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

Incidental Medical Services (IMS) policy was discussed. Applicant stated facility will not administer medication. 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 CONT 809-C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: TESFAZGY FCC AKA LITTLE WORLD CHILD CARE	FACILITY NUMBER: 406216190
	VISIT DATE: 10/26/2021

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No prohibited equipment will be allowed or used in the home. No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

All adults living and working in the home shall be made aware of the Department inspection rights authority.

LPA and Applicant reviewed Safe Sleep Regulations. LPA provided a copy of PIN 20-24 and LIC 9227 and reviewed regulations with Applicant.

LPA also advised against sleeping infants in a separate room.

During this visit, LPA assisted Applicant in registering email to receive Provider Information Notices (PINs). LPA reviewed Forms/Records to Keep in Your Family Child Care Home (LIC 311D) with the Applicant and Assistant. LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

Forms to be posted

LIC6101A Emergency Disaster Plan,
PUB394 Notification of Parents Rights Poster,
Facility License

Facility Records: LIC 624B Unusual Incident/Injury Report, LIC 9040 Child Care Facility Roster, LIC 9052 Employee Rights, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse.
CONT 809-C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: TESFAZGY FCC AKA LITTLE WORLD CHILD CARE	FACILITY NUMBER: 406216190
	VISIT DATE: 10/26/2021

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Staff Forms/Records - any assistant present must have the following on file: Proof of TB clearance (within one year), Notice of Employee Rights (LIC 9052), Criminal Record Statement (LIC 508), Statement Acknowledging Requirements to Report Suspected Child Abuse (LIC 9180).

Children’s records requirements: LIC 700 Identification and Emergency Information, LIC 627 Consent for Emergency Medical Treatment, LIC 282 Affidavit Regarding Liability Insurance, LIC 9150 Parent Notification Additional Children in Care, Immunization record, PUB 72- Family Child Care Consumer Guide, LIC 995A Notification of Parent’s Rights

Applicant was made aware the responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.

LPA reviewed and provided copy of Guidance for Child Care Providers and Programs updated on 06/29/2021. LPA reviewed and discussed over-night care regulations with Applicant and provided a copy of CCR 102426 for Applicant to review.

Exit interview was conducted with Applicant, Milen Tesfazgy. Notice of site visit was printed and posted by Applicant prior to LPA leaving the facility. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.

The home meets Title 22 Division 12 California Code of Regulations requirements of a Small Family Child Care Home (FCCH). Effective date of license is 10/26/2021.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC809 (FAS) - (06/04)

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