Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013326
Report Date: 01/26/2016
Date Signed 01/26/2016 02:01:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:DAVIS FAMILY CHILD CAREFACILITY NUMBER:
198013326
ADMINISTRATOR:DAVIS, ELAINE & WENDELLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 805-0005
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:14CENSUS: 5DATE:
01/26/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Elaine DavisTIME COMPLETED:
02:05 PM
NARRATIVE
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Random visit conducted by LPA Jennifer Hua. LPA met with licensee Elaine Davis. Licensee guided LPA on a facility tour. The facility is a two story home. The facility has 4 bedrooms and 4 bathrooms.Per licensee, people live in the home are 4 adults and 0 minors. The facility is also licensed for foster home #191009241.

Areas accessible to children were inspected as follows: one bedroom, one bathroom, side yard, and children eat in dining area.

Per licensee, there are no weapons, firearms, *swimming pool or spa on the premises. There are age appropriate toys and equipment on the premises. The smoke/carbon monoxide detectors and fire extinguisher (2A 10BC) are in operable condition.

CPR/First Aid Certificate will expire on 6/7/16.


-Child Care Roster, Disaster Plan, Children records and required licensing forms were reviewed as well as mandated child abuse reporting and criminal records clearance (finger prints and child abuse clearance) requirement.

The following was discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to licensure. Individuals within one month of their 18th birthday must be fingerprinted immediately. The existing, immediate $100 per individual Civil Penalty has been increased to an immediate $100 per day Civil Penalty, for a maximum of five days for the first violation and a maximum of 30 days for subsequent violations. If an individual has a clearance with the Department a criminal record clearance may be transferred. LIC 9182 Criminal Background Clearance Transfer Request may be used.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3395
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 854-6738
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2016
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 198013326
VISIT DATE: 01/26/2016
NARRATIVE
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Rooms that are off-limits need to be made inaccessible during operating hours.
No smoking, No infant walkers, Johnny jumpers, exersaucers, bouncers and any other item that falls into that category, earthquake – fire, disaster drills and safety, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal records, child abuse clearance and criminal records transfer requirements, SIDS, Never Shake A Baby, .


Incidental Medical Services discussed and explained. Per Licensee, IMS is not provided at this time. Licensee stated a written plan will be submitted to the Department 30 days prior to IMS being provided. Please refer to (FCCH EM Policy - 102417) for reference.

Deficiencies are cited on attached 809D. An exit interview conducted, a copy of the report given. Appeal rights explained and provided.

- Exit interview was conducted with licensee. Notice of Site Visit form was provided and explained. The notice must be posted 30 days or a civil penalty of $100.00 will be assessed.

Web site address to order forms: http://www.dss.cahwnet.gov/cdssweb/On-lineFor_293.htm#l
INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3395
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 854-6738
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2016
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 198013326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2016
Section Cited
102417(d)
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Operation of a Family Child Care Home. The home shall provide safe toys, equipment and materials. LPA observed a bouncer in the day care room.
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Removed and discarded during visit.
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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: Christina GabelmanTELEPHONE: (323) 981-3395
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 854-6738
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2016
LIC809 (FAS) - (06/04)
Page: 4 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 198013326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2016
Section Cited
102417(g)(8)
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Operation of a Family Child Home. All homes shall have a current roster of the children. No roster available for review.
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Per licensee, will correct and submit copy to Licensing.
Type B
02/01/2016
Section Cited
102417(g)(A)1
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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. No drills conducted.
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Per licensee will correct and submit copy to licensing.
Type B
02/01/2016
Section Cited
102417(g)(1)
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Operation of a Family Child Care Home. Fire extinguishers and smoke detectors shall meet State Fire Marshal Standards. LPA observed fire extinguisher has no service tag. Per licensee, hsa not been serviced.
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Per licensee, will correct and submit copy of service tag.
Type B
02/01/2016
Section Cited
102418(g)(1)
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Immunizations. The licensee shall document the immunizagtions and maintain updates for children in care. LPA observed 1 file lack record.
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Per licensee, will correct and submit copy to Licensing.
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: Christina GabelmanTELEPHONE: (323) 981-3395
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 854-6738
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2016
LIC809 (FAS) - (06/04)
Page: 3 of 4