198020754-11-24-2021-33-CC-LGOZ-C93QVT-20211124113053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020754
Report Date: 11/24/2021
Date Signed: 11/24/2021 11:31:08 AM

Document Has Been Signed on 11/24/2021 11:31 AM - 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	CAMARENA FAMILY CHILD CARE		FACILITY NUMBER:	198020754
ADMINISTRATOR:	MIRNA CAMARENA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 394-0945
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90065
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	11/24/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Mirna Camarena, Applicant		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 9:27AM on 11/24/2021, Licensing Program Analysts (LPA) Lissete Gonzalez conducted a pre-licensing inspection. LPA met with applicant, Mirna Camarena, who guided analysts on a tour of the home. Family members residing in the home include applicant’s father, applicant’s adult son, and applicant’s two minor children. The applicant is requesting a large family child care home license. Per applicant, operating hours will be from 6:00AM to 6:00PM from Monday through Friday. Applicant states that she will care for children age birth to 12 years of age. All areas identified on the facility sketch were inspected. This is a two story home which consists of 7 bedrooms, 3 restrooms, kitchen, dining room, living room, detached garage, front and backyard (fenced). The children will use the bedroom located by the front entrance to the home (Nap Room), bathroom in the hallway near kitchen, living room, dining room, kitchen, backyard, and garage. Applicant states the detached garage will be used for activities only. LPA observed an outdoor children’s restroom that will be subject to Department review and approval. Based on the Facility Sketch submitted, areas off limits to children and parents are: the entire 2nd floor, 6 bedrooms, 1 1/2 bathrooms and front yard. There is a child safety gate located on the stairs leading to the second floor to prevent access. The two off limits bedrooms located on the first floor will remain locked during operating hours. The applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary. Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service, and ventilation and heating (central air/heat). Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children were observed to be inaccessible. The kitchen cabinets and restroom vanity were observed to have child safety latches to prevent access. The children will use the back yard for outdoor play, which was observed to be fenced. There is a door in the backyard that leads to a basement. Applicant states the door will remain locked during operating hours. REPORT CONTINUES ON NEXT PAGE: 1 OF 5

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

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: CAMARENA FAMILY CHILD CARE	FACILITY NUMBER: 198020754
	VISIT DATE: 11/24/2021

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Per applicant, there are no firearms, weapons or bodies of water on the premises. Per applicant, there is one dog on the premises which will be kept in the off limits second floor and will not have contact with children. The applicant states that there are no poisons on the premises. The applicant was advised that any poisons must be locked with a key or combination lock.

The valve on the 2A10BC fire extinguishers indicates it’s fully charged. The fire extinguisher were serviced on 9/16/2021. Smoke and carbon monoxide detectors were tested and are operable. There are adequate age appropriate toys, books, and games. Applicant was advised that if food is brought from the children’s homes, all containers must be labeled with child’s name and properly stored or refrigerated. There are electrical outlet covers throughout and a First Aid supplies are available.

The applicant has the required Health and Safety Training, Nutrition Training and the applicant’s Pediatric First Aid/CPR expire on 03/31/2023. There are first aid supplies available.

LPA discussed COVID-19 precautionary measures with applicant including indoor face mask requirements; all staff and children over the age of 2 years old are required to wear a face mask while indoors except for activities such as eating or sleeping.

LPA obtained signed Declaration (LIC 855) forms regarding the following:
· Declaration of acknowledgment that the detached garage will be used for activities only. The garage will not be used by children in care for meals or sleeping and supervision will be maintained at all times.
· Declaration that applicant fully understands that she must live in the home at all times and must be present 80% of the time during operating hours.

UPDATE: Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com

Infant Care: Applicant states that she will care for infants. LPA provided applicant with a copy of PIN 20-24-CCP: Recently Approved Safe Sleep Regulations in Effect. LPA advised the applicant to sleep infants where they can be directly supervised at all times and advised against sleeping infants in a separate room.
REPORT CONTINUES ON NEXT PAGE: 2 OF 5

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: CAMARENA FAMILY CHILD CARE	FACILITY NUMBER: 198020754
	VISIT DATE: 11/24/2021

NARRATIVE

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The applicant states the following: Applicant states that she will sleep infants in a common area where they can be directly supervised. LPA provided the applicant with information for Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. Online copy can be downloaded at: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

Incidental Medical Services (IMS): 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

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. Civil Penalties will be assessed if not in compliance.
· 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 Pediatric First Aid and CPR certification and a valid criminal record clearance associated to the facility license.
· Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
· The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked and batteries replaced as needed.
· Reporting Requirements: 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.
· Reporting Requirements: 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.

REPORT CONTINUES ON NEXT PAGE: 3 OF 5

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: CAMARENA FAMILY CHILD CARE	FACILITY NUMBER: 198020754
	VISIT DATE: 11/24/2021

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· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
· No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
· 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.
· Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.
· Never Shake a Baby, Sudden Infant Death Syndrome (SIDS) and Safe Sleeping practices.
· Capacity Handout for a Small Family Child Care Home and Large Family Child Care Home was provided.
· UPDATE: H&S 1597.622: 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, and measles. The licensee and all adults working with children have proof of immunization.
· Liability Insurance: Per applicant, she will be obtaining liability insures. LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

LPAs advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms:

CHILDREN FORMS/RECORDS - Children’s files must contain the following documents/information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), Consent/Verification for Nebulizer Care (LIC 9166), California School Immunization Record, Parent Notification for Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Acknowledgment of Receipt of Licensing Reports (LIC 9224).

REPORT CONTINUES ON NEXT PAGE: 4 OF 5

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: CAMARENA FAMILY CHILD CARE	FACILITY NUMBER: 198020754
	VISIT DATE: 11/24/2021

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FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records: As required in Title 22 Regulations 102416.1, Unusual incident/Injury Report (LIC 624B): Child Care Facility Roster (LIC 9040), Notice of Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108), Property Owner/Landlord Consent (LIC 9149), Property Owner/Landlord Notification Form (LIC 9149).

INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME
You are required by Law to post the following:
Facility License (LIC 203), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parent’s Rights (PUB 394). A Notice of Site Visit (LIC 9213): Must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

Per applicant, there are no dual licenses at this address. Applicant’s email address was obtained during this inspection. The applicant was advised that email may be public information.

The following corrections need to be corrected prior to obtaining a small family child care license.
Corrections are due by 12/08/21.

Applicant will install a child safety gate on the exterior side of the home to prevent access to trash cans and barbeque grill.
Applicant submitted criminal record clearances for fingerprint transfers for father and adult son. Clearances must be processed before license is issued.
Department review of outdoor restroom usage.

A large family child care licensee will be granted upon receipt of proof of corrections for the above. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

Exit interview was conducted with Mirna Camarena.
END REPORT PAGE: 5 OF 5

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

LIC809 (FAS) - (06/04)

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