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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372010564
Report Date: 10/15/2021
Date Signed: 10/15/2021 05:29:08 PM

Document Has Been Signed on 10/15/2021 05:29 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CLARK, CHAN FAMILY CHILD CAREFACILITY NUMBER:
372010564
ADMINISTRATOR:CLARK, CHANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 225-1490
CITY:SAN DIEGOSTATE: CAZIP CODE:
92107
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 4DATE:
10/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Chan ClarkTIME COMPLETED:
05:30 PM
NARRATIVE
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On 10/15/21 at 11:50am, Licensing Program Analyst (LPA), Martha Malane conducted an unannounced Annual Inspection and met with Licensee’s helper, Erika Laraya. LPA disclosed the purpose of the inspection and was granted entry into the facility. Licensee, Chan Clark arrived at the facility at 12:20pm. Four (4) children and one (1) helper were present in the facility during this inspection. This facility is a single story, four (4) bedroom, two (2) bathroom house. The following areas are used for childcare: Bedroom #1, #2 and #3, bathroom #1, living room, den, family room, backyard and kitchen. The following off-limit areas are made securely inaccessible: Bedroom #4 and garage. Hours of operation are Monday – Sunday 5:00am to 9:30pm.

The fire extinguisher, smoke detector and carbon monoxide detector met requirements, per LPA observation. LPA observed hazardous items inaccessible to children in care. LPA informed licensee poisons shall be placed in a storage area and locked. LPA observed toys, play equipment and materials available for the children’s use. The home has a fenced backyard available for outdoor activities. LPA informed licensee children shall be supervised during outdoor activities. Licensee has a jacuzzi in the backyard which has a cover that locks at the time of this inspection. Licensee stated there are no weapons in the home. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal 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. Licensee’s First Aid and CPR certifications expired 6/2019. Licensee has required immunizations, per file review, however licensee’s helper does not have immunization records on file. Licensee is currently exempt from Mandated Reporter Training. The facility roster is maintained and was reviewed. The last fire and disaster drills were conducted and documented on 02/15/2021. There is one crib or play yard for each infant who is unable to climb out of the crib or play yard.
See LIC809C continuation...
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CLARK, CHAN FAMILY CHILD CARE
FACILITY NUMBER: 372010564
VISIT DATE: 10/15/2021
NARRATIVE
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At 12:00pm, LPA observed a sleeping infant in a play yard with blankets and a stuffed animal. The provider has not been physically checking on sleeping infants every 15 minutes. LPA and licensee, Chan Clark discussed safe regulations and LPA provided PIN 20-24-CCP and 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. Individual Infant Sleeping Plan [LIC 9227 (3/20)] has not been maintained for each infant up to 12 months of age, LPA provided a copy of an LIC9227 (3/20). The provider places infants up to 12 months of age on their backs for sleeping.

A Fire place located in the family room is not securely screened or gated as one of the glass panels is missing which makes the fire place accessible to children in care.

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.

LPA and licensee discussed 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.

LPA discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov. LPA discussed and provided Licensee with the following: child care advocates email address: [email protected]. LPA informed licensee, in order to sign up for Quarterly Updates and PINs through our website, please go to www.cdss.ca.gov and click on “Receive Important Updates”, input email address, choose which program(s) to subscribe to and click “subscribe. In addition, for general questions or questions regarding licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.
See LIC809C continuation...
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CLARK, CHAN FAMILY CHILD CARE
FACILITY NUMBER: 372010564
VISIT DATE: 10/15/2021
NARRATIVE
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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 an 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.

California Code of Regulations, (Title 22, Division 12 & Chapter 3), are being cited on the attached LIC 809-D pages. Exit interview conducted and report reviewed with licensee, Chan Clarke. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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Document Has Been Signed on 10/15/2021 05:29 PM - It Cannot Be Edited


Created By: Martha Malane On 10/15/2021 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CLARK, CHAN FAMILY CHILD CARE
FACILITY NUMBER: 372010564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that the fireplace is accessible to due to one of the glass panels being missing which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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Licensee stated she will screen the fireplace to make it inaccessible to children.
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observation and interviews, the licensee did not comply with the section cited above when a sleeping infant was in a play yard with blankets and pillows which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2021
Plan of Correction
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Licensee stated she will remove all items from cribs and play yards.
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:Tulam Vu
LICENSING EVALUATOR NAME:Martha Malane
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


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Document Has Been Signed on 10/15/2021 05:29 PM - It Cannot Be Edited


Created By: Martha Malane On 10/15/2021 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CLARK, CHAN FAMILY CHILD CARE
FACILITY NUMBER: 372010564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above when an infant was sleeping a room with the door closed in bedroom #3, which is at the back of the house without a monitored device which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2021
Plan of Correction
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Licensee will ensure the door to the bedroom where an infant is sleeping is open and she is able to hear the infant.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not ensuring her helper, Erika Laraya had a current mandated reporter training certificate on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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Licensee stated she will have her helpers and substitutes take the mandated reporter training and provide CCL with copies of the certificates by 10/22/21.
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:Tulam Vu
LICENSING EVALUATOR NAME:Martha Malane
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/15/2021 05:29 PM - It Cannot Be Edited


Created By: Martha Malane On 10/15/2021 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CLARK, CHAN FAMILY CHILD CARE
FACILITY NUMBER: 372010564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in that Child #1 and Child #2 do not have documentation of required immunizations on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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Licensee will submit proof of immunizations for Child #1 and Child #2 to CCL by 10/22/2021.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that her helper, Erika Laraya does not have documentation of a current CPR/First Aid certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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Licensee will submit proof of Erika Laraya's current CPR/FA certification to CCL by 10/22/2021.
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:Tulam Vu
LICENSING EVALUATOR NAME:Martha Malane
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 10/15/2021 05:29 PM - It Cannot Be Edited


Created By: Martha Malane On 10/15/2021 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CLARK, CHAN FAMILY CHILD CARE
FACILITY NUMBER: 372010564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in that each employee does not have a personnel record with required documents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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2
3
4
Licensee will ensure each employee has a file with required documents and submit proof to CCL by 10/22/21.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(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, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in that licensee's helper, Erika Laraya does not have immunization records on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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2
3
4
Licensee will send proof of immunization records for Erika Laraya to CCL by 10/22/21. Licensee stated that her daughter will help organize her files to ensure compliace with regulations.
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:Tulam Vu
LICENSING EVALUATOR NAME:Martha Malane
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 10/15/2021 05:29 PM - It Cannot Be Edited


Created By: Martha Malane On 10/15/2021 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CLARK, CHAN FAMILY CHILD CARE
FACILITY NUMBER: 372010564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in two (2) out of five [5) children's records did not have immunizations records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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2
3
4
Licensee stated she will obtain immunization records for Child #1 and Child #2 and submit proof to CCL by 10/22/21.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in three (3) out of three (3) infants do not have an LI9227 on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2021
Plan of Correction
1
2
3
4
Licensee will ensure that all infants enrolled have an LIC9227 on file and they are updated every 3 months. Licensee will submit proof of completed forms to CCL by 10/18/21.
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:Tulam Vu
LICENSING EVALUATOR NAME:Martha Malane
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 10/15/2021 05:29 PM - It Cannot Be Edited


Created By: Martha Malane On 10/15/2021 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CLARK, CHAN FAMILY CHILD CARE
FACILITY NUMBER: 372010564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in three (3) out of three (3) infants do not have a log to document 15 minute checks while sleeping which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2021
Plan of Correction
1
2
3
4
Licensee will create a log and document 15 checks for each sleeping. Licensee will submit a copy of the log to CCL by 10/18/21.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tulam Vu
LICENSING EVALUATOR NAME:Martha Malane
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


LIC809 (FAS) - (06/04)
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