Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017920
Report Date: 11/01/2017
Date Signed 11/01/2017 01:03:53 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:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
198017920
ADMINISTRATOR:LOPEZ, BLANCAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 927-9759
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY:14CENSUS: 3DATE:
11/01/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Blanca LopezTIME COMPLETED:
01:18 PM
NARRATIVE
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Licensing Program Analyst (LPA) Raul Navarro conducted an unannounced Annual/ Random inspection in Spanish. LPA met with Licensee Blanca Lopez who guided this LPA on a tour of the facility. Also present was Licensee's spouse, Jesus Lopez. There were 3 children present during today’s inspection. Licensee states that there are currently 4 children enrolled. The children's roster was reviewed and is current. Disaster drill log was also available and current.

This is a one story home which consists of 3 bedrooms, 2 bathroom, Day care room, kitchen, dining area, living room, garage and backyard. Per licensee, areas off limits to children and parents include: 2 bedrooms, 1 bathroom, kitchen, dining area, living room, front yard and garage.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. There is a working telephone maintained in the home. Family members residing in the home are 2 adults (criminal record clearances on file) and 2 children. Licensee has a pet dog. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible. Licensee states that there are no poisons in the home.

Per Licensee, there are no weapons, firearms or bodies of water on the premises. There are safe toys, play equipment and materials observed for children. Emergency Disaster Plan was posted at the time of inspection. Children’s records were reviewed to ensure that each child has an Identification and Emergency form. The valve on the required 2A 10BC fire extinguisher indicates fully charged, serviced 11/29/2016. Smoke detector in the living room and carbon monoxide detector in the hallway were tested and are in operable condition. The Licensee has current Pediatric First Aid and CPR, which will expire on 05/2018.
Report continues- Page 1 of 3
SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-2956
LICENSING EVALUATOR NAME: Raul NavarroTELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2017
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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 198017920
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2017
Section Cited
HSC
1597.622
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Employees or volunteers at family day care home; immunization requirements; records; exemptions
(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis,
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Licensee will submit proof of immunization for herself and for spouse to LPA by POC date.
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and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
Licesee did not provide proof of immunization against influenza, pertussis, and measles for herself and spouse.
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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: Katherine HarewoodTELEPHONE: (323) 981-2956
LICENSING EVALUATOR NAME: Raul NavarroTELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2017
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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 198017920
VISIT DATE: 11/01/2017
NARRATIVE
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Incidental Medical Services (IMS): The Licensee states that she will not administer any medication. If the Licensee chooses to administer prescription medication in the future, she must refer to California Title 22 Regulations Section 102417 for additional information on regulatory requirements.

The Licensee was advised how to access forms and Regulations online at www.ccld.ca.gov. Licensee was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care.

The licensee’s email address was obtained during this inspection. The licensee was advised that email is public information.

LPA issued the Confidential Names List (LIC 811) to the licensee during this visit. The Confidential Names List documents the children’s files that were reviewed during this inspection.

The deficiency listed on the following page was observed by the LPA and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

Exit interview was conducted with Licensee. The Licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.
SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-2956
LICENSING EVALUATOR NAME: Raul NavarroTELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2017
LIC809 (FAS) - (06/04)
Page: 3 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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 198017920
VISIT DATE: 11/01/2017
NARRATIVE
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The following was discussed with the applicant:
Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

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. A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility. 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 2-A10BC must be serviced annually or as often as necessary and smoke detectors should checked and batteries replaced as needed. 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. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Fire and safety drills must be performed every six months and documented for review by the Department. Smoking is prohibited in a family child care home. Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

Baby walker, excersaucers, bouncers or any similar items are prohibited. All adults living and working in the home shall be made of 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. Role and responsibilities of being a Mandated Reporter were reviewed.

LPA reviewed and issued the LIC 311D - Forms/Records to Keep in Your Family Child Care Home. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed. A hard copy of A Child Care Provider’s Guide to Safe Sleep was provided.
Report continues- Page 2 of 3
SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-2956
LICENSING EVALUATOR NAME: Raul NavarroTELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2017
LIC809 (FAS) - (06/04)
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