Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415246
Report Date: 09/25/2015 12:00:00 AM
Date Signed: 09/25/2015 03:31:11 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:MATAL-BANOS FAMILY CHILD CAREFACILITY NUMBER:
197415246
ADMINISTRATOR:MATAL-BANOS, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 509-0587
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:14CENSUS: 5DATE:
09/25/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Ana Matal-BanosTIME COMPLETED:
03:35 PM
NARRATIVE
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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. There were 5 children ( 2 infants) present at the time of the visit. LIcensee's home is a two story home. Licensee's home consists of 4 bedrooms, 2 bathrooms, living room, family room, dining room, kitchen and garage. The second floor remains a guest home, occupied by the licensee's son and it consists of 1 bedroom, living room, kitchen and bathroom. The second floor is only accessible from the backyard. There is a pool in the back yard with a fence that measures 5 feet in height. The space between the cement floor and the pool gate is 2 inches. Spacing between the vertical beams are 4 inches apart and there are at least 45 inches between the horizontal beams. LPA tested the pool gate and observed it to be self-closing and self-latching. There are no other bodies of water on the premises. Family members residing in the home include 3 adults (licensee, spouse and 1 adult son) and 2 children. Main care is provided in the Living room. Children use the bathroom in the hallway and are escorted, as this area is primarily off-limits. Children eat and nap in the living room area and in the bedroom adjacent to the living room. . Off limit areas include the remainder of the home. The bedroom doors all have safety covers on the knobs; making the rooms inaccessible. The second floor is also completely off-limits Licensee reports there are no firearms or weapons in the home. The LPA did not observe any weapons. There are age appropriate toys and napping equipment on the premises. LPA also observed Licensee's current Pediatric CPR (Adult/Infant /Child) and Pediatric First Aid certifications (expire 09/2017). 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 is off limits to the children in care. 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 stored in the kitchen inaccessible to children in care. There are working smoke/carbon monoxide detectors located in the play room. LPA observed the fire drill log. Licensee states the fire drills are done every month. Fire drills logs were available for review. Fireplace is properly screened.
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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (310) 337-4826
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2015
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, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME: MATAL-BANOS FAMILY CHILD CARE
FACILITY NUMBER: 197415246
VISIT DATE: 09/25/2015
NARRATIVE
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LPA toured the front yard and found it to be fully fenced. . Children's outdoor play equipment and toys are age appropriate and in good repair.

Licensee has the following documents posted in the FCCH; Facility License (LIC 203), Notification of Parents' Rights Poster (PUB 394) , Emergency Disaster Plan (LIC610a).
Licensee did not have a Child Care Facility Roster (LIC9040).

A review of the children's records was conducted and are found to have the following: , 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 (Blue) Card.
LPA observed missing Immunization record for 3 children only.
LPA observed file for Child # 5 to be missing Consent for Emergency Medical Treatment from ( LIC 627).


Exit interview conducted the following was discussed with the licensee:



Licensee was informed of responsibility to report suspected Child Abuse by calling the Child Abuse Hotline at 1-800-540-4000. Also call the Community Care Licensing office and follow up with a written Unusual Incident/Injury Report (LIC 624B).

The licensee was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The licensee may find additional information and forms on the Department’s website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507.

LPA discussed AB633 and informed licensee that, upon receipt of a Type A deficiency, the licensee shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Licensee is reminded that smoking is prohibited on the premises during hours of operation
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (310) 337-4826
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2015
LIC809 (FAS) - (06/04)
Page: 2 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, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME: MATAL-BANOS FAMILY CHILD CARE
FACILITY NUMBER: 197415246
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2015
Section Cited
102418(g)
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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
LPA reviewed children's files and observed missing Immunization record. Records missing for 3 children only.
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Licensee will fax or mail copies of Immunizations records for the 3 children by 10/02/15. Licensee will keep documentation of the immunization records in each child's file.
Type B
10/02/2015
Section Cited
102417(g)(8)
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Operation of a Family Child Care Home. All homes shall have a current roster of the children.

Licensee did not have a facility roster.
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Licensee shall complete a current roster ( LIC 9040) and submit a copy to the Department no later than 10/02/15.
Type B
10/02/2015
Section Cited
102417(g)(7)
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Operation of a Family Child Care Home: LPA reviewed children's records and observed file for Child # 5 to be missing Consent for Emergency Medical Treatment from ( LIC 627).
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Licensee states she will have the parents complete Form LIC 627 or have the parent write a signed statement if they not Consenting to Emergency treatment. In this case, sufficient emergency phone numbers must be provided. Licensee will fax copies to LPA by 10/02/2015.
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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: (310) 337-4826
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2015
LIC809 (FAS) - (06/04)
Page: 3 of 3