Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409882
Report Date: 07/05/2018
Date Signed: 07/05/2018 03:03:25 PM

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:GUZMAN FAMILY CHILD CAREFACILITY NUMBER:
197409882
ADMINISTRATOR:GUZMAN, ISABELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 763-7849
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91601
CAPACITY:14CENSUS: 9DATE:
07/05/2018
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH: Juan Oliva Ornelas/spouse/assistantTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Silva Garibyan conducted a site visit for the purpose of a Required-3 Year visit . LPA met with the licensee's assistant/spouse and toured the home inside and outside. LPA observed 9 children in care ( including three infants and no school age child). The licensee was not present at the time of the visit. Licensee’s home has 2 bedrooms and 2 bathrooms. Primary child care is provided in the living room and in the family/day care room. Children in care have access to the bathroom in the day care room. Licensee's assistant reports they have no firearms or weapons in the home. LPA also observed Licensee's and assistant's current Pediatric CPR (Adult/Infant /Child) and Pediatric First Aid certifications (expire 01/2019). Family members residing in the home include 2 adults (licensee and her husband) and no children. Napping equipment was observed. The bathroom and the kitchen. observed free of chemicals or toxic items that can pose danger to children in care. The Fire Extinguisher (2A-10-BC) was in the living room. There is a working smoke and Carbon Monoxide detectors located in the living room. The First Aid kit was observed, and complete. The back yard is being used for day care children. There is no pool or other bodies of water on the premises. The back yard is fully fenced. The garage in the back is off limits to the children in care.. 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. Page 1 of 3
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2018
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GUZMAN FAMILY CHILD CARE
FACILITY NUMBER: 197409882
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2018
Section Cited
HSC
1597.622
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Employees or volunteers at family day care home; immunization requirements; records; exemptions: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.
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The licensee shall ensure all employees or volunteers at the family day care home , have been immunized against influenza, pertussis, and measles. For those choosing to waive the influenza vaccine, proper documentation must be on file. The licensee must show proof of immunization no later than the close of business on 8/05/18
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Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
Per assistant staff immunization's are not up to date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2018
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: GUZMAN FAMILY CHILD CARE
FACILITY NUMBER: 197409882
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/05/2018
Section Cited
CCR
102416.5
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STAFFING RATIO AND CAPACITY
The capacity specified on the license shall be the maximum number of children for whom care can be provided
Licensee's spouse/assistant was alone with 9 children in care (including three infants).
Licensee was not present at the time of the visit
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Licensee was advised that she must remain within her ratio at all times. LPA also reminded assistant that if there is no assistant present, her capacity reverts back to a small capacity
Plan of Correction Visit will be conducted.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2018
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: GUZMAN FAMILY CHILD CARE
FACILITY NUMBER: 197409882
VISIT DATE: 07/05/2018
NARRATIVE
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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
Exit interview conducted with the assistant, during which appeal rights were explained. A copy of the appeal rights and the report were provided.

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

DATE: 07/05/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2018
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: GUZMAN FAMILY CHILD CARE
FACILITY NUMBER: 197409882
VISIT DATE: 07/05/2018
NARRATIVE
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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. Licensee's and assistant's immunization are not 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.

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

DATE: 07/05/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2018
LIC809 (FAS) - (06/04)
Page: 2 of 5