Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192007738
Report Date: 11/30/2016
Date Signed 11/30/2016 03:37:40 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 FAMILY CHILD CAREFACILITY NUMBER:
192007738
ADMINISTRATOR:SAN GERMAN, MARIA GERARDOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 767-0313
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:14CENSUS: 4DATE:
11/30/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Maria San GermanTIME COMPLETED:
03:35 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 the licensee and toured the home inside and outside. The licensee was present with 4 children (no infants). 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. 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. There is no pool, spa or other bodies of water on the premises. Family members residing in the home include the licensees, and their three adult children. Licensee has an operating smoke/carbon monoxide detectors in the child care room as well as an operating and fully charged Fire Extinguisher. Licensee reports she has no firearms or weapons in the home. LPA also observed Licensee's 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.
LPA observed toys and furniture that were age appropriate and in good repair.
LPA observed the fire drill log. The fire drills are done every month.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (310) 337-4826
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2016
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 FAMILY CHILD CARE
FACILITY NUMBER: 192007738
VISIT DATE: 11/30/2016
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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.

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment

Update on Incidental Medical Services: Facilities that provide Incidental Medical Services (IMS) must identify those services in their facility’s Plan of Operation and submit an updated Plan of Operation to the Department. Incidental Medical Services Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering EpiPen Jr. and EpiPen or other Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Emptying an Ileostomy Bag. Please see Child Care Quarterly Report on www.ccld.ca.gov

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: 11/30/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2016
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 FAMILY CHILD CARE
FACILITY NUMBER: 192007738
VISIT DATE: 11/30/2016
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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.

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.

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

DATE: 11/30/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2016
LIC809 (FAS) - (06/04)
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