Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418595
Report Date: 08/21/2015 12:00:00 AM
Date Signed 08/21/2015 03:43:02 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:WINDOM FAMILY CHILD CAREFACILITY NUMBER:
197418595
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
08/21/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Julie WIndomTIME COMPLETED:
03:42 PM
NARRATIVE
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Licensing Program Analyst (LPA) Khadarian conducted an unannounced site visit. The licensee has submitted an application for increase of capacity; fire marshal has approved the capacity for 14 children. Present at time of visit were the licensee and 4 daycare children (3 of whom were infants). LPA was guided on a tour of the facility inside and outside. There are no changes to the facility layout or to the off limit areas. Upon arrival, LPA observed the childproof gate installed in the hallway to make the bedrooms off limits. The following were observed during this visit:

1. All adults living and working in the home are fingerprint cleared and associated to the facility. Licensee has two tenants who are fingerprint cleared and associated.
2. The backyard is completely fenced in. The in-ground pool is completely fenced with mesh fencing that meets the Title 22 Regulation requirement. The gate was tested to open away from the bodies of water and was self closing/self latching. There are no objects around the fence that makes it climbable.
3. The toys were observed to be abundant, in good repair and age appropriate. The swing set was observed to be anchored properly.
4. There were no baby walkers or exersaucers.
5. According to the licensee, there are no firearms or other dangerous weapons in the home; none were observed.
6. The home has working telephone service.
7. The home is equipped with operable smoke detectors, 2A10BC fire extinguisher and a carbon monoxide detector.
8. The kitchen and bathroom used by the children was inspected for inaccessibility of chemicals and sharp objects.
9. The home has current and accurate children's roster.
10. The licensee has current pediatric CPR/1st aid training valid through May 30, 2017.
SUPERVISOR'S NAME: Bill MayedaTELEPHONE: (310) 337-4341
LICENSING EVALUATOR NAME: Shoghig KhadarianTELEPHONE: (310) 337-4308
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2015
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: WINDOM FAMILY CHILD CARE
FACILITY NUMBER: 197418595
VISIT DATE: 08/21/2015
NARRATIVE
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12. LPA review sample children's files to be complete and included all the required licensing forms.
13.. The licensee was advised to obtain licensing forms and most recent regulatory updates from the Licensing website at ccld.ca.gov and more specifically the Quarterly Updates.
14. The licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed.
15. Licensee is advised that effective January 1 2012 only non-flavored, unsweetened nonfat (fat free skim, 0%)or low-fat (1%) milk can be served to children. No beverages with added sweeteners can
be served (this includes sodas, sweet teas, juice drinks with added sugars, flavored milks and diet drinks) A maximum of one serving (4-6 ounces for 1 to 6 year olds) of 100% juice will be allowed per day.
15. Incidental Medical Services was discussed during this visit. Licensee has medication policy but does not include IMS. Per licensee, she does not have children who require these services at this time.

The facility was cited under Title 22 Regulations. Copy of this report was provided. Exit interview
SUPERVISOR'S NAME: Bill MayedaTELEPHONE: (310) 337-4341
LICENSING EVALUATOR NAME: Shoghig KhadarianTELEPHONE: (310) 337-4308
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2015
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: WINDOM FAMILY CHILD CARE
FACILITY NUMBER: 197418595
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2015
Section Cited
102417(g)(8)
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Operation of a Family Child Care Home. All homes shall have a current roster of the children.Licensee admitted to not have created a roster for the children enrolled.
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The licensee agrees to adhere to this regulation. She will create and maintain a roster at all times. She will use the LIC 9098 (Proof of Correction) form provided to her during this visit.
Type B
09/04/2015
Section Cited
102417(g)(9)(A)
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Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Licensee was unable to produce proof of conducting drills.
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Licensee agrees to conduct emergency drills as required. Additionally, once she is licensed for large FCCH, she is reminded to conduct monthly drills. The LIC 9098 (Proof of correction) form will be submitted to Licensing.
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She reported that she has attempted to conduct the drills at one time but not kept a record.
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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: Bill MayedaTELEPHONE: (310) 337-4341
LICENSING EVALUATOR NAME: Shoghig KhadarianTELEPHONE: (310) 337-4308
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2015
LIC809 (FAS) - (06/04)
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