Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417875
Report Date: 06/02/2016
Date Signed 06/02/2016 10:54:12 AM

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:CONSTON FAMILY CHILD CAREFACILITY NUMBER:
197417875
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
06/02/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
07:55 AM
MET WITH:Jennifer NietoTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Silva Garibyan conducted a site visit for the purpose of an Annual Random visit . The licensee has applied for capacity increase. The licensee was not present at the time of the visit. LPA met with the licensee's assistant ( cleared, associated, and CPR/First Aid certified) and toured the home inside and outside. The assistant ( #1) was present with 3 children and assistant # 2 ( not associated to the facility and has been employed for two months). LPA observed the assistant #2 working with the children in the back yard. The licensee has installed the pull fire alarm that is required for large Family Child Care Homes and has an approved fire clearance. LIcensee's home is a single story 3 bedroom, 2 bathroom home, with living room, family room and kitchen. There is a detached garage that is not used for any child care activities. There is no pool, spa or other bodies of water on the premises. Family members residing in the home include 2 adults (licensee and spouse) only. LPA observed assistant's current Pediatric CPR (Adult/Infant /Child) and Pediatric First Aid certifications (expire 8/2016). Main care is provided in the family room and living room. The bathroom located between the bedrooms and the bedrooms remain off limits and are locked when children are in care.
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. There is a working smoke/carbon monoxide detectors located in the family/play room.
LPA inspected the rear yard and observed the area to be free of hazardous items. Children play on both the grass and cement areas. Children also play in the front yard, which is enclosed by a fence. Children are supervised at all times when playing outdoors.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (310) 337-4826
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2016
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 4


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: CONSTON FAMILY CHILD CARE
FACILITY NUMBER: 197417875
VISIT DATE: 06/02/2016
NARRATIVE
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Licensee has the following documents posted in the FCCH; Facility License (LIC 203), Notification of Parents' Rights Poster (PUB 394). The Emergency Disaster Plan (LIC610a) was not posted in the facility.

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 assistant incidental medical services are not and will not be provided.
Licensee is advised to visit www.shotsforschool.org for Immunization information.
SB 277 - require all children attending day care or school based programs to be immunized and will eliminate personal/religious belief exemptions

Licensee's assistant was informed that the deficiencies would be discussed with the Licensing Program Manager before a decision can be made on the approval of licensee's requested capacity increase.

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: 06/02/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2016
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: CONSTON FAMILY CHILD CARE
FACILITY NUMBER: 197417875
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2016
Section Cited
102370(d)(1)
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Criminal Record Clearance: LPA observed assistant #2 present in the home and caring for children. Assistant stated this is her second month working in the facility. This poses an immediate safety risk to children when unfingerprinted adults work in the home and have direct contact with them.. Civil Penalty assessed.
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Assistant #2 must complete Live Scan and may not return to work in the facility until all clearances are received. Copy of Live Scan due to CCL by 06/06/2016 or a statement indicating that assistant #2 will not return to work in the facility.
Plan of Correction (POC) visit will be conducted.
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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: 06/02/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2016
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: CONSTON FAMILY CHILD CARE
FACILITY NUMBER: 197417875
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2016
Section Cited
102417(g)(9)
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Operation of a Family Child Care Home. Each home shall have a written disaster plan prepared on a form approved by the Department. Everyone in the home, age and ability permitted, shall be instructed of their duties under the disaster plan.
Disaster Plan was not posted in the facility
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Licensee to update and post Emergency Disaster Plan (LIC 610a).

Plan of Correction (POC) visit will be conducted.
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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: 06/02/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2016
LIC809 (FAS) - (06/04)
Page: 4 of 4