Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192002492
Report Date: 12/19/2018
Date Signed: 12/21/2018 08:13:16 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
192002492
ADMINISTRATOR:HERNANDEZ, MARTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 764-3427
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:14CENSUS: 9DATE:
12/19/2018
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Martha Hernandez/LicenseeTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Silva Garibyan conducted a site visit for the purpose of an Required - 3 Year visit . LPA met with the licensee and toured the home inside and outside at 11:00 a.m on 12/19/2018.. There were 9 children present at the time of the visit ( including three infants). Licensee has one assistant ( cleared and associated to the facility). All areas identified on the facility sketch were inspected. 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 or in the day car 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. Licensee reports she has no firearms or weapons in the home. Family members residing in the home include four adults and one child ( licensee's 14 year old daughter). LPA observed napping equipment, small tables and chairs. The bathroom and the kitchen was observed free of chemicals or toxic items that can pose danger to children in care. 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. LPA also observed Licensee's and assistants current Pediatric CPR (Adult/Infant /Child) and Pediatric First Aid certifications (expire 12/28/2018).The Fire Extinguisher is mounted on the wall in the kitchen. There is a working smoke and Carbon Monoxide detectors located in the day care room. The First Aid kit was observed, and complete. Page 1 of 3
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2018
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 192002492
VISIT DATE: 12/19/2018
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Update on Incidental Medical Services:

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

Mandated Reporter: Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. Website: www.mandatedreporterca.com.



The licensee was informed of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541
Email Address: childcareadvocatesprogram@dss.ca.gov
The facility is operating in substantial compliance with the Title 22 Regulations at time of visit.
No violations were cited. A copy of this report along with a Notice of Site Visit were issued and explained to licensee.

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2018
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 192002492
VISIT DATE: 12/19/2018
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LPA observed the fire drill log. The fire drills are done every month.
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.

The following was thoroughly discussed with the licensee:

Assembly Bill 633: Upon receipt by the licensee, licensees are to provide to parents/guardians the following: Copies of any licensing reports that document a Type A citation- this includes facility visits and substantiated complaint investigations; copy of licensing documents pertaining to a conference conducted by a local licensing agency management representative and the licensee of this family child care home in which issues of noncompliance are discussed or copies of a summary of an accusation indicating the Department's intent to revoke the facility's license. Copies of any of the above licensing documents the licensee has received in the prior 12 months shall be provided to parents/guardians of newly enrolled child at the facility.

Senate Bill 792: This bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles. Staff immunization records are up to date.

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment

New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint. Page 2 of 3
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2018
LIC809 (FAS) - (06/04)
Page: 2 of 3