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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416405
Report Date: 04/27/2022
Date Signed: 04/27/2022 01:19:04 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/27/2022 01:19 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:KOWALCZYK FAMILY CHILD CAREFACILITY NUMBER:
197416405
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Cynthia Kowalczyk, LicenseeTIME COMPLETED:
01:32 PM
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On April 27, 2022, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced Required 1 Year inspection at the above facility. Upon arrival LPA was greeted by licensee. LPA observed 2 preschool age children. The licensee is operating within proper capacity and ratios. LPA observed licensee to be present at the home and providing adequate care and supervision. Hours of operation are Monday through Sunday, 04:00 AM to 10:00 PM.

The home is a one story house with 4 bedrooms and2 bathrooms laundry area with chemicals and cleaning compounds inaccessible to children in care, living room, dinning room, kitchen and completely fenced rear yard.

The day care takes place in living room, dinning room, rear bedroom and hallway bathroom and rear yard. The home is clean, orderly, comfortable and well ventilated.

Licensee's poisons, detergent, cleaning compounds, medications and other items which could pose a danger to child are stored where they are inaccessible to children. LPA observed working smoke detector and Carbon Monoxide, fully charged fire extinguisher and working telephone. There are several age appropriate toys and a first aid kit on the premises. Per the licensee, there are no firearms on the premises. The licensee has current CPR and first aid that expires 06/2022.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KOWALCZYK FAMILY CHILD CARE
FACILITY NUMBER: 197416405
VISIT DATE: 04/27/2022
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The licensee has completed the online mandated reporter training at www.mandatedreporterca.com, and will renew 06/2022
All childcare employees must complete mandated reporter training within 30 days of hire and renew training every two years

The licensee has the required immunization's.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, 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

Licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B

The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).

The licensee was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KOWALCZYK FAMILY CHILD CARE
FACILITY NUMBER: 197416405
VISIT DATE: 04/27/2022
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The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507

Per the licensee, fire and disaster drills are conducted every 6 months; last drill documented and conducted on 02/03/2020.

Licensee has the required documents posted in the FCCH; Facility License (LIC 203), Emergency Disaster Plan (LIC610a), Notification of Parents' Rights Poster (PUB 394).

The following was discussed with the licensee:


Capacity requirements, Roster requirements, Posting requirements, Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children’s files and provider’s files, and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. Licensee was reminded that supervision is always required to children in care.

Licensee was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care. Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified.

Regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KOWALCZYK FAMILY CHILD CARE
FACILITY NUMBER: 197416405
VISIT DATE: 04/27/2022
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--Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
-- Our Quarterly updates come out every 3 months they are also now in Spanish please log in to the CCLD website or you can email our advocates to have the quarterly updates send directly to your email. Child Care Advocates information: [email protected]

The on Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 AM - 5:00 PM.

A copy of Safe Sleep Proposed Regulations was provided to Licensee.

LPA provided consultation during inspection.

There are no deficiencies being cited at this time, facility is in compliance with Title 22 Regulations.

An exit Interview was conducted, a copy of this Report and a Notice of Site visit was provided to the licensee.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC809 (FAS) - (06/04)
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