Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407897
Report Date: 10/08/2015
Date Signed: 10/08/2015 01:23:59 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:RIVERA FAMILY CHILD CAREFACILITY NUMBER:
197407897
ADMINISTRATOR:EDITH RIVERAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 287-1691
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY:14CENSUS: 4DATE:
10/08/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Edith RiveraTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Joanne Alcala conducted an annual random visit at the above facility. Upon arrival LPA was greeted by licensee, Edith Rivera. LPA observed a total of 4 children. Per Licensing Information System (LIS) all adults residing and working in the home have obtained background clearances. Per LIS, facility annual fees are current. The licensee is operating within proper capacity and ratios. LPA observed licensee to be present at the home and providing adequate care and supervision.

The home is clean, orderly, comfortable and well ventilated. LPA observed a working smoke detector and Carbon Monoxide, fully charged 2A10BC fire extinguisher and working telephone. There are several age appropriate toys and a first aid kit on the premises. Knives and medications are in accessible to children. Kitchen and bathroom areas were inspected for inaccessibility of toxins/cleaning compounds and other potentially dangerous objects/materials. Electrical outlets around the home were properly covered. The attached garage is off limits as well. The backyard is completely fenced in. There are no bodies of water in the FCCH. Per the licensee, there are no firearms on the premises. The licensee has current CPR and first aid that expires 9/2017.

SUPERVISOR'S NAME: Scott HerringTELEPHONE: (310) -33-4313
LICENSING EVALUATOR NAME: Joanne AlcalaTELEPHONE: 310-337-4335
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2015
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: RIVERA FAMILY CHILD CARE
FACILITY NUMBER: 197407897
VISIT DATE: 10/08/2015
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Licensee has the required documents posted in the FCCH; Facility License (LIC 203), Emergency Disaster Plan (LIC610a), Notification of Parents' Rights Poster (PUB 394), Child Care Facility Roster (LIC9040), and Disaster Drill log.

LPA observed a current child roster. Per the licensee, fire and disaster drills are conducted monthly. Child files were found to be complete.

Key indicator Tool 3 was utilized during this inspection.


Incidental Medical Services were discussed. Licensee stated that at this time she does not serve any children with IMS.
The following was discussed with the licensee;
No smoking, No infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category, earthquake safety and necessity of drills (every 6 months), required forms for children’s files, facility files, posting requirements, penalty, fingerprint clearance, and the transfer process and penalty.
For additional information and forms visit our website at: www.ccld.ca.gov
A copy of this report must be made available to the public for 3 years.

Per the Title 22 regulations, on 10/8/15, the above facility was found to be operating in substantial compliance.

An exit Interview was conducted, a copy of this Report and a Notice of Site visit was provided.

SUPERVISOR'S NAME: Scott HerringTELEPHONE: (310) -33-4313
LICENSING EVALUATOR NAME: Joanne AlcalaTELEPHONE: 310-337-4335
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2015
LIC809 (FAS) - (06/04)
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