Internal Web Data

Department of
SOCIAL SERVICES

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 192002492
Report Date: 02/11/2016
Date Signed: 02/11/2016 03:39:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230

FACILITY NAME:	HERNANDEZ FAMILY CHILD CARE		FACILITY NUMBER:	192002492
ADMINISTRATOR:	HERNANDEZ, MARTHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 764-3427
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	14	CENSUS: 13	DATE:	02/11/2016
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Martha Hernandez		TIME COMPLETED:	03:40 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) Silva Garibyan conducted a site visit for the purpose of an Annual Random visit . LPA met with the licensee and toured the home inside and outside. LPA observed 13 children present. Licensee's two assistants were present at the time of the visit. The licensee's home is a single story 4 bedroom, 3 bathroom home with living room, kitchen and day care room. The day care room is located at the front of the home and has its own exterior entrance. The day care room was previously a garage and it has been legally converted. (Permit is on file). There is no pool, spa or other bodies of water on the premises. Main care is provided in the day care room. Children nap in the living room and eat in a dining area of the kitchen. Children use the bathroom inside the day care room. Off limit areas include 3 of the home's bedrooms and 2 bathrooms. 1 bedroom that is accessible from the day care room is used for napping and passage to the living room. The home was found to be clean and orderly with proper ventilation for safety and comfort. The bathroom was inspected for inaccessibility of chemicals/toxins and other potential hazards to children in care. The kitchen cabinets and drawers were inspected for inaccessibility of toxins/chemicals, knives and other sharp objects which may be harmful to children in care. The Fire Extinguisher (3A-40-BC) is mounted on the wall in the play room. There is a working smoke/carbon monoxide detector located in the play room. Licensee has current CPR or First Aid. Current CPR and First Aid taken 01/2015 expire 01/17. The First Aid kit was observed, and complete. LPA observed toys and furniture that were age appropriate and in good repair.

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (310) 337-4826
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2016

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2016

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, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230

FACILITY NAME: HERNANDEZ FAMILY CHILD CARE	FACILITY NUMBER: 192002492
	VISIT DATE: 02/11/2016

NARRATIVE

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Licensee provides transportation for school aged children to school in the mornings and from school in the afternoons. Licensee ensures proper child seat restraints, maintains vehicle insurance and registration and current driver license for the driver. Licensee is aware that children must never be left in a parked vehicle.
Children play in the front and side yards which were observed to be fenced and children are supervised. Back yard is off limits to the children in care.

Licensee has the following documents posted in the FCCH; Facility License (LIC 203), Notification of Parents' Rights Poster (PUB 394) , Child Care Facility Roster (LIC9040), Emergency Disaster Plan (LIC610a).

A review of the children's records was conducted and are found to have the following: LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization Card.

Incidental Medical Services were discussed. Per licensee incidental medical services are not and will not be provided.

No deficiencies were observed during this inspection; the facility is in substantial compliance at this time.

Exit interview was conducted and a copy of the report was provided.

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (310) 337-4826
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2016

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2016

LIC809 (FAS) - (06/04)

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