Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192007738
Report Date: 11/10/2015
Date Signed 11/10/2015 04:48:14 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:SAN GERMAN & ZAMORA FAMILY CHILD CAREFACILITY NUMBER:
192007738
ADMINISTRATOR:SAN GERMAN & ZAMORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 767-0313
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:14CENSUS: 4DATE:
11/10/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Maria San GermanTIME COMPLETED:
04:00 PM
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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 Licensee and toured the home inside and outside. There were 4 children ( 1 infant, 3 school age) present at the time of the visit. LIcensee's home is a single story 3 bedroom, 3 bathroom home with living room, dining area, kitchen, den (used as a bedroom) and a guest room at the rear of the home. The guest room was previously the garage and has been legally converted; the garage door has been removed and a carport added. There is no pool, spa or other bodies of water on the premises. Family members residing in the home include 3 adults (licensee, co-licensee {son} and spouse and 2 minor children (17 and 13 years old). All adults have a criminal record clearance and are associated to the facility. There is no pool, spa or other bodies of water on the premises. Main care is provided in the guest room at the rear of the home. Children have access to the living room, dining area and kitchen as well. Off limit areas include the home's 3 bedrooms and the den. The home also has a laundry room and storage room that is accessible from the back yard. Off-limits rooms were observed to have the doors closed; however, no safety devices were observed and the doors were not locked. Licensee was advised to ensure their inaccessibility by placing safety devices on the door knobs or ensuring that all of the doors are locked when children are in care. Licensee reports she has no firearms or weapons in the home. LPA also observed Licensees' current Pediatric CPR (Adult/Infant /Child) and Pediatric First Aid certifications (expire 10/2017).

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 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 (2A-10-BC) is mounted on the wall in the kitchen inaccessible to children in care. There is a working smoke and carbon monoxide detectors located in the living room. The First Aid kit was observed and complete. LPA observed the fire drill log. Licensee states the fire drills are done every month. Fire drills logs were available for review.


SUPERVISOR'S NAME: Mary RuizTELEPHONE: (310) 337-4826
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2015
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: SAN GERMAN & ZAMORA FAMILY CHILD CARE
FACILITY NUMBER: 192007738
VISIT DATE: 11/10/2015
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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) 6, Child Care Facility Roster (LIC9040).

Children play outside in the back yard only. The yard is fenced and gated. Children play primarily under the carport. Vehicles are parked at the rear of the yard, near the gate that leads to the alley. There is a second gate/fence used to separate the parking area from the play area. The right side of the home has 2 gates and was observed to be clean and clear. Licensee has 2 dogs that are kept in the den during the day. Children do not interact with the pets.

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: 11/10/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2015
LIC809 (FAS) - (06/04)
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