Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197420034
Report Date: 01/21/2016
Date Signed 01/21/2016 12:49:55 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:MUNOZ GONZALEZ FAMILY CHILD CAREFACILITY NUMBER:
197420034
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
01/21/2016
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Zivia Munoz GonzalezTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Karren Starks made an announced visit for the purpose of conducting a Pre-Licensing inspection. LPA met with and toured the home with applicant, Zivia Munoz Gonzalez. The home is a single story 2 bedroom 1 bathroom home with living room, dining room, kitchen and rear room area. Entrance into the facility will be via a walkway that leads to the rear of the home with entry into the rear room. Bedroom #1 is off the hallway to the right, belongs to the applicant and her husband it is off limits and made inaccessible by lock. Bedroom #2 is off the hallway to the left and belongs to the applicant's sons, ages 7 & 12 and is off limits and made inaccessible by lock. The bathroom for children in care is located off the hallway, it was inspected and LPA did not observe any medications, toxins or cleaning compounds that would cause a risk to children in care.
The home appeared to be clean, safe and well ventilated with telephone service. There is a properly barricaded fireplace in the living room that is used to heat the home. The kitchen which is through the dining room to the right, is off limits and made inaccessible by a child safety gate. LPA observed the cabinets and drawers to have safety latches, making all contents inaccessible to children in care. There was a fully charged 2A10BC Fire Extinguisher mounted in the kitchen.
Main care will be provided in the rear room, LPA observed age appropriate toys and furniture in the rear room. The area will be heated by a portable heater that will heat the area prior to children arriving. The furnace for the home in inoperable and the grates, located in the hallway are covered. The dining room is just to left of the living room and will only be used if the weather does not permit the children to go outdoors. All electrical outlets in areas that will be used for child care are covered. LPA also observed mats for napping.
There is a small Chihuahua in the home that may interact with the children, applicant reminded that the dog's shots must be kept current and should me made available if requested. LPA observed a complete First Aid Kit. Current First Aid/CPR and Preventive Health are on file. There are operable smoke/carbon monoxide detectors in the home. LPA observed the Deed for the home. There is a shotgun and BB gun with trigger locks and the ammunition kept separate, in the closet. Incidental Medical Services (IMS) were discussed with the applicant.
The backyard was inspected for outdoor use it is fully enclosed. LPA observed a covered patio area and two storage sheds.
SUPERVISOR'S NAME: Scott HerringTELEPHONE: (310) 337-4313
LICENSING EVALUATOR NAME: Karren StarksTELEPHONE: (310) 337-3753
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2016
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: MUNOZ GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 197420034
VISIT DATE: 01/21/2016
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LIC 9040 Child Care Facility Roster (Retain for 3 years) most recent must be posted
LIC 9148 Earthquake Preparedness Checklist
LIC 627 Consent for Medical Treatment
LIC 702 Child's Preadmission Health History-Parents Report
LIC 995 Notification of Parent's Rights
PUB 394 Notification of Parent's Rights Poster 12/06 ( issued & discussed)
LIC 613-A Personal Rights
LIC 700 Identification and Emergency Information
LIC 282 Affidavit Regarding Liability for Family Child Care Homes
LIC 9224 Acknowledgement of Receipt of Licensing Reports 12/06 (issued & discussed)
Title 22, Division 12 Regulations ( access website)
SIDS & SHAKEN BABY SYNDROME INFORMATION (issued & discussed)
Applicant was informed of responsibility to report suspected Child Abuse 1-800-540-4000
Applicant was informed all adults 18 years of age and older living in the home or visiting for extended periods of time SHALL have criminal background clearances with the Department of Justice, FBI and Child Abuse Index Check. Applicant was informed if any adults 18 years of age and older do not meet these requirements a Civil Penalty of $500.00 will be cited for each adult.
Applicant was informed of the following items that must be posted in visual site once licensed.
(1) License (2) Emergency Disaster Plan (3) Children’s Roster (4) Parents Rights Poster PUB 394, Personal Rights LIC 613-A Recent regulatory changes were discussed. CDSS forms, web site www.ccld.ca.gov and live scan (electronic fingerprinting agency ) 800-315-4507.
Exit interview was conducted including but not limited to provider's rights, appeal rights, appeal procedures, and agencies consultative role.
SUPERVISOR'S NAME: Scott HerringTELEPHONE: (310) 337-4313
LICENSING EVALUATOR NAME: Karren StarksTELEPHONE: (310) 337-3753
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2016
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: MUNOZ GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 197420034
VISIT DATE: 01/21/2016
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The shed to the left is locked and has gardening items inside. In front of this shed were a key lime, avocado and mandarin orange tree. The shed to the right is also used for storage and has a shower and sink inside, this will be made inaccessible by lock. There is a fire pit in the middle of the yard that the applicant will cover. To the right of the yard closer to the house is a garden with vegetables. To the rear of the house is the applicant's washer and dryer, with the cleaning detergents high on a shelf making them inaccessible to children in care. LPA did not observe any bodies of water in the yard. Applicant also wishes to periodically use the front yard which is gated for outdoor use. The applicant needs to put a latch on the gate that encloses trash bins.

LPA discussed with applicant requirements under Title 22 Regulations.

All adults living or working in the home must have valid criminal record clearances associated to the license, failure to associate criminal record clearances shall result in an immediate civil penalty of $100.00 per day for each adult found in the home not having a valid clearance associated to the license.
In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license. Staff must also have current immunization.

A roster with the names of children who have attended the family child care home must be maintained for a period of three years, even after the child is no longer attending the child care home.
Adult and infant CPR & Pediatric First Aid must be maintained current and valid regardless whether children are being cared for or not.
Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License shall be terminated.
The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke detectors should have battery replacements at least twice a year.
Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
Activities such as fulltime employment and/or fulltime attendance to a school are not allowed when children are present and you are actively operating the license.
SUPERVISOR'S NAME: Scott HerringTELEPHONE: (310) 337-4313
LICENSING EVALUATOR NAME: Karren StarksTELEPHONE: (310) 337-3753
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2016
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: MUNOZ GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 197420034
VISIT DATE: 01/21/2016
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Unusual incident & injury report shall be reported by the licensee to the Department within 24 hours via telephone and within seven (7) days in writing.
Fire and safety drills must be performed at least two (2) times a year and documented for review by the Department and the local fire authority.
Smoking tobacco in a family child care home during the hours of operation is prohibited
Children and Staff records must be maintained and updated as needed and must be available for review by Licensing Analyst
Baby walker, exersaucers, bouncers and similar items are prohibited
The licensee is responsible for keeping up with changes in the regulations and forms. Information can be access 24hrs/7days at www.ccld.ca.gov
All adults living and working in the home shall be made aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

Before licensure, the following needs to be corrected/completed:

The fire pit must be covered

The crawl space must be covered

The work table must be removed

Latch on the door for the shed to the right must be in place

Latch on the shed for the trash bins must be in place



Applicant advised that all corrections are due within 30 days or the application may be denied.
SUPERVISOR'S NAME: Scott HerringTELEPHONE: (310) 337-4313
LICENSING EVALUATOR NAME: Karren StarksTELEPHONE: (310) 337-3753
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2016
LIC809 (FAS) - (06/04)
Page: 3 of 4