Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419988
Report Date: 08/13/2015 12:00:00 AM
Date Signed 08/13/2015 02:52:33 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:MARTIN FAMILY CHILD CAREFACILITY NUMBER:
197419988
ADMINISTRATOR:MARTIN, THERESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 531-2064
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY:14CENSUS: 0DATE:
08/13/2015
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Theres Martin, ApplicantTIME COMPLETED:
10:05 AM
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LPA Sharalyn Jenkins-Sweeten conducted an announced prelicensing visit. LPA Jenkins-Sweeten met with Theres Martin, applicant, who guided analyst on a tour of the facility. All areas identified on the facility sketch were inspected. This is a single story home. The home was inspected as follows: Kitchen, living room, dining room, family room (primary care area), 3 bedrooms, 2 bathroom, front yard and backyard. Family members residing at facility are 2 adult. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. The First Aid kit was observed mounted on a kitchen wall. Per applicant, there are no weapons or firearms of any kind in the facility at this time. The LPA did not observe any weapons. There is no pool, spa or other bodies of water on the premises. There are age appropriate toys and equipment on the premises. The required fire extinguisher size 2A10BC, smoke detector and carbon monoxide detector are in operable condition. The applicant has provided copies of current Pediatric CPR and Pediatric First Aid certificates which expire 3/2017. The applicant has submitted an emergency disaster plan and demonstrated control of property at the above address by presenting a copy of the rental agreement from the property owner's agent, Shane Edele. Applicant must utilize the affidavit regarding liability insurance or purchase an insurance police with a minimum of $300,000 in coverage.

Areas off limits include: 3 bedrooms, rear bathroom, living room, backyard
Rooms/Areas were made inaccessible by: Bedrooms have keyed door knob locks, which also prevent access to the rear bathroom. Living room has a securely latched accordion door and latched hall door.
Backyard has an iron safety gate on west side of driveway and locking backdoor which prevents access.

The following are prohibited walkers, walkers without wheels, jumpers & bouncers and the like are not allowed in day care facilities, capacity limitations, personal rights, Child Safety Seat Law, Notification of Parent's Rights revised 12/06, inspection authority, licensee appeal/procedure rights & agency's
SUPERVISOR'S NAME: Bill MayedaTELEPHONE: (310) 337-4341
LICENSING EVALUATOR NAME: Sharalyn Jenkins-SweetenTELEPHONE: (310)568-2448
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2015
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: MARTIN FAMILY CHILD CARE
FACILITY NUMBER: 197419988
VISIT DATE: 08/13/2015
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consultative role. Smoking is prohibited on the premises when children are present. The LPA also discussed earthquake safety and the necessity of documenting dates/times of drills minimally once every 6 months, required forms for children’s files, facility files and posting requirements. The applicant was also informed that all adults living in or having access to day care children in the home are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the aforementioned is not adhered to, a Civil Penalty of $100 /day per uncleared adult will be assessed.

Incidental Medical Service (IMS) is the ability for a licensee to provide care for children with unusual medical conditions that need services beyond first aid (Blood glucose monitoring, administering Inhaled meds, Epi-Pen/Epi-Pen Jr., glucagon, gastrostomy tube feeding and care, etc.) which can be done by a non-skilled medical professional given that certain criteria are met, documents are available for review and they have submitted an update to the facility’s plan of operation (P of O) describing the policies and procedures in place to ensure safe practices. Refer to Title 22 Regulations Section 102417. Licensee stated IMS services are not being provided at the facility at this time.
*** IF CITED FOR TYPE A VIOLATION ***
Upon receipt, licensee shall post the report for 30 days in addition to the Notice of Site Visit & provide copies of the licensing report to parents/guardians of children in care at the facility by the close of business the following day or the next day child returns to the facility. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee will obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Note: Repeated violations within 12 months will be assessed a civil penalty.

During the inspection, LPA obtained verification of control of property, applicant's current copies of Pediatric CPR and Pediatric First Aid, Statement Acknowledging Requirement to Report Child Abuse, Landlord Notification, applicant's TB test results and Criminal Record Statement for applicant and her adult daughter.

The following corrections are required prior to licensure and due no later than 9/12/15:
1) Obtain Landlord's/Property Owner's signature on Landlord Consent

A copy of this report was explained and issued to the applicant, Theres Martin.
SUPERVISOR'S NAME: Bill MayedaTELEPHONE: (310) 337-4341
LICENSING EVALUATOR NAME: Sharalyn Jenkins-SweetenTELEPHONE: (310)568-2448
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2015
LIC809 (FAS) - (06/04)
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