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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334843709
Report Date: 01/18/2022
Date Signed: 01/18/2022 10:28:31 AM

Document Has Been Signed on 01/18/2022 10:28 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:KELLY FAMILY CHILD CAREFACILITY NUMBER:
334843709
ADMINISTRATOR:KELLY, ASHLEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 692-0006
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
01/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley KellyTIME COMPLETED:
10:45 AM
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On date and time listed, Licensing Program Analyst (LPA) Alaina Wilburn arrived at the facility to conduct an annual inspection as part of a compliance review. Upon arrival to facility, Licensee advised LPA she plans to close her day care, because she and her family are relocating to another state. She is continuing to operate, while remaining parents find replacement child care. The last day of operation is Friday, January 28, 2022. During today's visit, Licensee provided LPA with a closure letter, and Licensee was instructed to return the original license when she stops operating. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:

· Normal days and hours of operation are: Monday through Friday, 6:00AM to 6:00PM

· Off-limit areas include: Second floor, Garage and Backyard

· The facility is operating within the licensed capacity and appropriate ratios


· Appropriate supervision provided during this inspection

· A working telephone is present and the current number is on file

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.

· Fireplace is properly screened to prevent access by children

· All hazardous items are stored inaccessible to children

· Toxins are locked

· Weapons are not present according to Title 22. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

SUPERVISORS NAME: Stephanie Hudak
LICENSING EVALUATOR NAME: Alaina Wilburn
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: KELLY FAMILY CHILD CARE
FACILITY NUMBER: 334843709
VISIT DATE: 01/18/2022
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· Clean, safe and age appropriate toys

· Current roster on file

· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted

· Documentation of fire and disaster drills on file (December 9, 2021)

· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

· Verification of control of property on file (lease agreement)

· Employee’s records are complete

· Mandated Reporter Training completed

· Pediatric CPR and First Aid Card expire on 10/24/2022

· Health & Safety Certificate - completed on 12/13/2015



· Resident and/or staff records were reviewed and all adults who require caregiver background checks have received all required clearances and/or exemptions.

The licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

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
SUPERVISORS NAME: Stephanie Hudak
LICENSING EVALUATOR NAME: Alaina Wilburn
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: KELLY FAMILY CHILD CARE
FACILITY NUMBER: 334843709
VISIT DATE: 01/18/2022
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and the ADA, available at: http://www.ada.gov/childqanda.htm
The Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: [email protected]

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.



The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to [email protected]. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

An exit interview was conducted, and this report was reviewed with the licensee Ashley Kelly. Appeal rights were discussed and provided during the exit interview.



A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Stephanie Hudak
LICENSING EVALUATOR NAME: Alaina Wilburn
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC809 (FAS) - (06/04)
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