Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300609833
Report Date: 10/12/2016
Date Signed 10/12/2016 01:43:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:WARD, CLAUDIAFACILITY NUMBER:
300609833
ADMINISTRATOR:WARD, CLAUDIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 539-1044
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:14CENSUS: 11DATE:
10/12/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Claudia Ward - LicenseeTIME COMPLETED:
01:30 PM
NARRATIVE
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LPA Jane Cong-Huyen met with licensee, Claudia Ward, for a annual random visit (2). The licensee was out of the home running errands when LPA arrived, few minutes later the licensee arrived home. LPA toured areas of the home inside and outside and areas accessible to the children. The home is a one level home with 3 bedrooms and 2 bathrooms. Licensee stated that OFF LIMITS areas include: all bedrooms, left side of yard, storage shed and large workshop shed. The licensee has barricaded that area so the children does not have access to that area. Licensee acknowledged that children may never enter these off-limit areas. The census includes 11 daycare children with ages ranging from 18 months to 4 years old. (2 infants and 9 preschoolers) Licensee stated there are no new residents in the home since licensed. Also present at time of visit was the licensee's 3 adult assistants who have also been fingerprinted. Licensee stated that she is not registered with any Foster Care agency. A review of family member/staff records on this date indicates that all family members and/or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was able to show proof of CPR (exp: 6/30/17) and First Aid (exp: 6/30/17) that is EMSA certified and all of the assistants. LPA observed posted Parent's Rights and current disaster plan. LPA also reviewed children's records and children's roster. Fireplace contains a screen. Licensee stated there are no weapons in the home. LPA observed all sharp utensils, hazardous chemicals and medication are stored up high or in latched/locked cabinet which is inaccessible to children in care. Fire extinguisher, smoke and carbon monoxide detectors meet regulations. Licensee must provide 100% visual supervision when the children are in an unfenced area. The home has 2 small dogs with immunization documents. No bodies of water at the home. LPA also discussed about the new SB792 for immunization for all of the adults working and residing in the home. Licensee will be sending proof of immunization (Influenza, Pertussis and Measles) to LPA by or before 11/11/16.
Deficiency cited during today's visit. (see LIC809D)
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2016
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: WARD, CLAUDIA
FACILITY NUMBER: 300609833
VISIT DATE: 10/12/2016
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(Random Annual Report, page 2)


LPA discussed the Incidental Medical Services (IMS) with the licensee and she states that she is planning to provide IMS and will submit the IMS plan/procedure to LPA by or before 11/11/16. This facility plans to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. A Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Deficiency cited during today's visit. (see LIC809D)

Exit interview was conducted. Report reviewed and discussed. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Appeal rights provided and explained if violation was issues. The director/licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. LPA informed the director/licensee of how to access regulations and forms from CCLD websites: www.ccld.ca.gov or Myccl.ca.gov. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2016
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: WARD, CLAUDIA
FACILITY NUMBER: 300609833
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2016
Section Cited
H&S 1597.622(c)
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Employees or volunteers at family day care home; immunization requirements; records; exemptions: The family day care home shall maintain documentation of the required immunization or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the family day care home.
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Licensee states that she was not aware of the new SB792 law. She will gather all proof of immunization for herself and assistants to LPA by or before 11/11/16.
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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: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2016
LIC809 (FAS) - (06/04)
Page: 3 of 3