Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418657
Report Date: 10/07/2015
Date Signed: 10/07/2015 03:21:10 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:GARCIA FAMILY CHILD CAREFACILITY NUMBER:
197418657
ADMINISTRATOR:GARCIA, SOILAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 755-3934
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:14CENSUS: 4DATE:
10/07/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Soila GarciaTIME COMPLETED:
03:30 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. The licensee's home is a single story home with 3 bedrooms and 3 bathrooms, living room, family room, kitchen, laundry room, and detached garage used for child care activities only. Licensee understands that children may not eat or sleep in the garage. The new laundry room/bathroom outside near the garage is still under construction. Licensee informed LPA ( prior to alteration the licensee also informed LPA Wendy Corleto) that the backyard is temporarily off limits to children in care due to construction work. A new facility sketch will be provided to Department. There is no pool, spa or other bodies of water on the premises. Family members residing in the home include 4 adults and 2 children; all adults have criminal record clearances. Main care is provided in the living room and family room, as identified on the facility sketch. The garage is used as a playroom and for storage of outdoor toys. When children are playing in the garage, the main garage door is kept open. LPA observed cots and play pens in the family room, where children nap. Children eat in the dining portion of the living room. Children use the bathroom accessible from the hallway. Off limit areas include the home's 3 bedrooms, the bathroom inside the bedroom and the bathroom inside the laundry room. The off limit rooms are made inaccessible by safety devices on the door knobs. Licensee has a dog that has access to the back yard and is kept behind the fence when children go outside to play. Licensee was unable to demonstrate current proof of CPR/First Aid Certificates. Licensee reports there are no firearms or weapons in the home.
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.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (310) 337-4826
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2015
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: GARCIA FAMILY CHILD CARE
FACILITY NUMBER: 197418657
VISIT DATE: 10/07/2015
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The Fire Extinguisher (2A-10-BC) is mounted on the wall in the kitchen inaccessible to children in care. There is a working smoke/carbon monoxide detector located in the play room.

LPA observed toys and furniture that were age appropriate and in good repair. .LPA toured the backyard and found it to be fully fenced.

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.

Exit interview was conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (310) 337-4826
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2015
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, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME: GARCIA FAMILY CHILD CARE
FACILITY NUMBER: 197418657
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2015
Section Cited
102416(c)
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:Licensee is required to maintain current Pediatric CPR and First Aid certifications at all times..
Licensee was unable to demonstrate current proof of CPR/First Aid Certificates
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Licensee will provide proof of current Pediatric CPR & Pediaric First Aid certifications or registraion for by 10/14/15.
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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: 10/07/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2015
LIC809 (FAS) - (06/04)
Page: 2 of 3