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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364841453
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:07:47 PM


Document Has Been Signed on 04/25/2024 01:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:BOOKER/CHAVEZ FAMILY CHILD CAREFACILITY NUMBER:
364841453
ADMINISTRATOR:S.BOOKER & A.CHAVEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 728-3445
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY:14CENSUS: 8DATE:
04/25/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staceylynn Booker and Ashlynn Chavez TIME COMPLETED:
01:20 PM
NARRATIVE
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On the date and time listed, Licensing Program Analyst (LPA) Aman Lama arrived at the facility to conduct an annual inspection. Upon arrival, LPA was met with license, Stacey Booker. Present during todays inspection was also co-licensee, Ashlynn Chavez and other adults that reside in the home. Licensee granted access to LPA who then toured the facility, both inside and outside.

Normal days and hours of operation are listed as: Monday-Friday 6:00am-6:30pm
OFF LIMIT AREAS INCLUDE: Bedroom, Room, Office, Stairs, Entire 2nd Floor, and Garage. Due to the weather, the backyard is not being utilized by daycare children, but was inspected and in compliance with Title 22 Regulations.
· Licensee understands the licensed capacity and appropriate ratios.
· A working telephone is present and current phone number is on file.

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector were all in working order.

· There were some hazards and toxins accessible, however, no children were present.

· No guns/weapons currently kept in the home. All guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations.

· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster were posted in the home.

· Mandated Reporter Training certificate for licensee expires 03/26.

· Pediatric CPR and First Aid Card for licensee expires 07/25.

· Health & Safety Certificate has been completed by both licensees and is on file.

· LPA observed Clean, safe and age appropriate toys available for children.

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 805-5718
LICENSING EVALUATOR NAME: Aman LamaTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: BOOKER/CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 364841453
VISIT DATE: 04/25/2024
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·Bodies of water were observed on property at this time. All bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains were observed to be properly fenced per Title 22 Regulations. The Department must be notified before and after installation of any of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

· Documentation of last fire/disaster drill was conducted: 03/11/2024

· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

· Resident and/or staff records reviewed indicate that all adults who require caregiver background checks have received all required clearances or exemptions.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations862@dss.ca.gov

- LPA reminded licensee of the safe sleep regulations and discussed the Child Care Licensing Safe Sleep webpage as an additional resource at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep

-LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

-Licensee is not currently administering medications. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes 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

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 805-5718
LICENSING EVALUATOR NAME: Aman LamaTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: BOOKER/CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 364841453
VISIT DATE: 04/25/2024
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- The licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.



- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at: 951-782-4200.

The Licensees Booker/Chavez both confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the licensee, Stacey Booker.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 805-5718
LICENSING EVALUATOR NAME: Aman LamaTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/25/2024 01:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: BOOKER/CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 364841453

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 residents of the home. There were no TB tests on file for 3 persons. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Licensees agree to submit proof of TB clearances for 3 adults residing in the home no later than POC due date.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and licensees own admission, the licensee did not comply with the section cited above. The licensees did not have 15 minute safe sleep logs on file for the infants in care. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensees agree to submit proof of safe sleep logs for all infants in care no later than the POC due date. Infants up to 24 months of age must have a safe sleep log on file.
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: Kimberly WilliamsTELEPHONE: (951) 805-5718
LICENSING EVALUATOR NAME: Aman LamaTELEPHONE: (951) 970-7385
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5