Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013326
Report Date: 07/26/2016
Date Signed 12/02/2016 03:32:11 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:
07/26/2016
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Wendell Davis & Elaine Chevalier aka DavisTIME COMPLETED:
04:35 PM
NARRATIVE
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**This is an amended report to add Assistants name and change the wording in the report from not having a clearance at all to not being associated to the facility**

Licensing Program Analyst (LPA) Adriana Hernandez conducted a case management deficiency inspection. Upon arrival to the Davis Family Child Care, LPA met with co-licensee Wendell Davis. Licensee Elaine Chevalier (aka Elaine Davis) arrived shortly after.

There were five napping children in day care bedroom. Children were being supervised by Assistant Ariana Olmera aka Ariana Iniguez. After a review of the personnel roster, which is a list of adults whom have obtained a background check clearance, it was discovered that Ariana is not associated to the day care.

Licensee Elaine stated that Ariana has already obtained a clearance however; LPA informed Licensee Elaine that as of today 7/26/16; Ariana’s clearance has not been transferred and/or associated to the Davis Family Child Care. LPA informed Licensee Elaine that an immediate $100 civil penalty will be issued due to the fact that per Licensee her assistant Ariana has been working at the facility since the first week or second week of July 2016.

The notice of site visit was posted where the parent/guardian of children enter and exit the facility. This notice shall be posted for 30 consecutive days. Failure to maintain posting as required shall result in a $100 civil penalty. Appeal Rights were discussed and were provided with a copy of their appeal rights (LIC 9058 FAS 01/16). Signature on this form acknowledges receipt of these rights.

Copies of this report must be posted for 30 days in a visible location for the authorized representatives of children. A copy of this report must be provided to the authorized representatives of all currently enrolled children and must also be provided to newly enrolled children for the next 12 months. The report shall be provided no later than the next business day or the next day the child is in care.

The Acknowledgment of Receipt of Licensing Reports (LIC9224) shall be signed and kept in each of the children’s records. Web site address to obtain forms, review updates, review Title 22 & Health & Safety Codes is: www.ccld.ca.gov. The following deficiency is being cited in accordance to Title 22 of the California Code of Regulations and Health & Safety codes. Exit interview conducted with licensee Elaine Chevalier aka Elaine Davis.
SUPERVISOR'S NAME: Bertha ManzanaresTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Adriana HernandezTELEPHONE: 323-981-3431
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2016
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, 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: 07/26/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2016
Section Cited
102370(d)(2)
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Criminal Record Clearance. Prior to working, or volunteering in a licensed home, all licensees & personnel as specified shall request a transfer of a criminal record clearance as specified in Section 102370 (j).- Assistant Ariana Olmera aka Ariana Iniguez did not have a clearance transfer.
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Licensee stated that she will obtain a copy of Ariana's identification and send that along with the Criminal Background Clearance Transfer Request LIC9182 to the Department no later than 07/29/16.
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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: Bertha ManzanaresTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Adriana HernandezTELEPHONE: 323-981-3431
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2016
LIC809 (FAS) - (06/04)
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