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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100440
Report Date: 01/13/2022
Date Signed: 01/13/2022 09:49:55 AM

Document Has Been Signed on 01/13/2022 09:49 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:FRIDBERG, POLINA FAMILY CHILD CAREFACILITY NUMBER:
376100440
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 5DATE:
01/13/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Polina FridbergTIME COMPLETED:
10:00 AM
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On 1/13/2022 at 8:30 a.m. Licensing Program Analyst (LPA), Leilani Curtis conducted an unannounced inspection in reference to the licensee’s request for an increase in capacity. Upon arrival LPA met with Licensee and toured the facility inside and outside per facility sketch. This 3 bedroom, 3 bathroom home was inspected to ensure an environment safe for the care and supervision of children. Present during the time of inspection were 5 day care children, none of whom were infants. The facility was observed operating within ratio and capacity. The licensee and children were observed not wearing face masks. LPA reminded Licensee that masks are required inside the facility and that children aged 2 and older should be taught and reminded to wear face coverings. Licensee is using the following areas for daycare: living room, dining room, kitchen, bedroom #2, bedroom #3, bathroom #2, bathroom #3 and enclosed rear yard. Off-limits areas include: bedroom #1 (master bedroom), bathroom #1 (located within master bedroom), laundry room and garage.

Licensee has provided adequate space for the children to eat, sleep and play within the home. Home is clean, orderly and has adequate ventilation. Children’s toys and play equipment are available and observed free of hazards. Stairs are barricaded. There is a working telephone/email address. All cleaning compounds, detergents, medications, and poisons are made inaccessible through latches, locks, and/or placed up on high surfaces. Fireplace is screened. The fire extinguisher, carbon monoxide detector, and smoke detector meet requirements and are operational. The fire clearance was granted on 12/14/21. Licensee states there are NO firearms or other weapons in the home. The outdoor play area is fenced and free of hazardous items. There are no existing bodies of water present. There is a water fountain located in the rear yard which the licensee states is non-operational. There was no water in the fountain at the time of inspection. Licensee understands that she must contact the Department and have the fountain inspected prior to its use. A review of staff records on this date indicates that all adult residents and helpers who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Pediatric CPR and First-Aid certificates are valid through 2/8/2022. Licensee meets immunization requirements and Mandated Reporter Training AB 1207 was completed on 7/11/2020 and is valid through 7/11/2022.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2022
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: FRIDBERG, POLINA FAMILY CHILD CARE
FACILITY NUMBER: 376100440
VISIT DATE: 01/13/2022
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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

LPA reviewed the following with Licensee: Updated Coronavirus 2019 Industry Guidance PIN 21-18-CCP, California Department of Public Health Guidance for Child Care Providers dated 6/29/21, California Department of Public Health Guidance for the Use of Face Coverings dated 7/28/2021 and capacity limitations. Licensee is reminded that corporal punishment, smoking, walkers, exersaucers, jumpers and bouncy seats shall never be permitted during daycare operation. Licensee is aware that interference with a child’s daily functions, corporal punishment, physical and mental abuse is not allowed. Licensee is reminded to make anything that reads, "Keep Out of Reach of Children" inaccessible to children.



No deficiencies are cited. No corrections are needed; a license for 14 children will be sent for posting.

LPA reviewed this report with Licensee and provided a copy of her Appeal Rights (LIC 9058 01/16). Her signature on this form acknowledges receipt of these rights. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA observed Licensee post notice of site visit.

Access our updated Regulation & Forms by using our WEBSITE: http://ccld.ca.gov.
Duty Officer: (619) 767- 2248, Monday thru Friday 8am-5pm.

Child Care Providers can now sign up for Quarterly Updates and PINS through the DSS website. Please go to www.ccld.ca.gov and click on Child Care, go under Quick Links and Quarterly Updates, click on “Receive Important Updates” then enter your email address and choose which program(s) you would like to subscribe to and click “subscribe”.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
LIC809 (FAS) - (06/04)
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