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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157700063
Report Date: 12/22/2021
Date Signed: 12/22/2021 03:13:12 PM

Document Has Been Signed on 12/22/2021 03:13 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:MELVIN FAMILY CHILD CAREFACILITY NUMBER:
157700063
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 1CENSUS: 1DATE:
12/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Applicant Chunte MelvinTIME COMPLETED:
03:25 PM
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On December 22, 2021 at 10:50AM, Licensing Program Analyst (LPA) Brigitte Tsutaoka met with Applicant, Chunte Melvin, who guided LPA on a tour of the facility for a Pre-licensing inspection. This is a single story 2 bedroom, 1 bathroom home with kitchen/dining, and living room. The home used for day care is the Back House (BH) on the same property of the Applicant's home. There is no pool/spa or body of water on the premises. Family members residing in the home include 1 adult (applicant) and one child. Incidental Medical Services (IMS) policy was discussed.

Main care is provided in BH Bedroom #2 (bedroom directly at end of the hallway). Children use the bathroom in hallway (first room on the left). Off limits areas include the entire Front House (FH) (FH Bedrooms #1 through #3, FH Bathroom #1 and #2, FH Kitchen, FH Living Room, FH Dining Room, and FH Attached Garage), and BH kitchen. The home was inspected inside and out for safety, comfort, cleanliness, telephone service (land line), heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (locked under BH kitchen sink), medicines (FH Bathroom) and hazardous items (sharp knives locked under kitchen sink) that can pose a danger to children. Applicant reminded to conduct fire/earthquake drills every 6 months and document. A Roster was provided to Applicant to complete and maintain.

The backyard is completely fenced. There is an anchored outdoor play structure. LPA observed the tube slide have cracks and is in need of repair. Applicant agreed to remove slide and fence off opening to make safe for children in care before licensure. There is one dog that stays in FH with dog run made inaccessible by gate.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Brigitte Tsutaoka
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MELVIN FAMILY CHILD CARE
FACILITY NUMBER: 157700063
VISIT DATE: 12/22/2021
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Per Applicant, there are no weapons or firearms on the premises. LPA did not observe any in the home at this time. There are age appropriate toys. Age appropriate napping equipment (cots). The required fire extinguisher (2A10BC), smoke detector, and carbon monoxide detector are in operable condition. Fireplace screened. Home has central AC and heat. CPR/First Aid expire 07/20/2023. Preventive Health and Safety completed 11/20/2021 with Lead Poisoning Prevention and Child Nutrition. The First Aid kit was observed and is complete. Applicant has no-touch thermometer.

The following was discussed with the Applicant:
Mandatory Forms for the children’s files and provider’s files. Requirements for fire drills, earthquake drills and documentation for both. Role and responsibilities of being a mandated reporter were reviewed. Applicant reminded that 100% supervision is required at all times to children in care. Applicant was advised how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov . Applicant was made aware that it is her responsibility to know the regulations as well as anyone who assists in providing care. Applicant was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must have the facility’s phone number at all times; 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 child care 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.

--Applicant is advised visit www.shotsforschool.org for Immunization information.
--Applicant was informed of responsibility to report suspected Child Abuse, 1-800-827-8724/760-243-6640
--Family Child Care Providers (Disaster Planning information): https://ccld.family-child-care-providers/disaster-planning-and-fire-safety/
--Child Care Videos: https://ccld.childcarevideos.org
--Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
--Applicant advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Brigitte Tsutaoka
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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: MELVIN FAMILY CHILD CARE
FACILITY NUMBER: 157700063
VISIT DATE: 12/22/2021
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--Provider Information Notice (PIN) Summary - PIN 18-02-CCP; Family Child Care Providers (Disaster Planning information):https://cccld.childcarevideos.org/family-child-care-providers/disaster-planning-and-fire-safety/

Applicant 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 LIC624. Pamphlet Information regarding SIDS, Seat Belt Safety, and Notification of Parent's Rights poster (Palmdale Regional Child Care Office) were provided. The "Notification of Parent's Rights" poster must be posted in an area of the home accessible to parents. The information regarding new legislation with regards to exemptions and Parent’s Rights was also discussed.

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

Requirements for fingerprint clearances and associations were discussed with the Applicant. The applicant was informed that all adults living in or having access to the home are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately.

Applicant informed to review Quarterly updates/regulations for 2021/2022.

Applicant was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Brigitte Tsutaoka
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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: MELVIN FAMILY CHILD CARE
FACILITY NUMBER: 157700063
VISIT DATE: 12/22/2021
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If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. Copies of the reports must also be provided to each parent when a serious deficiency, Type A, is cited (LIC9224).

During inspection, COVID-19 technical assistant was provide. Completed Child Care Program COVID-19 Self-Assessment in facility file.

The On Duty Worker is available for questions at 661-202-3318 Monday through Friday 8:00AM-5:00PM. LPA provided consultation during the inspection.
Before licensure the following must be completed:
1. Applicant must submit picture of repaired play structure.

Once corrections have been verified, the application for a small Family Child Care Home will be submitted for approval with a maximum capacity of 6 or 8 with parent notification. Applicant advised that all corrections are due within 30 days or the application may be withdrawn.

An exit interview was conducted, and a copy of this report was read and provided to the Applicant on this date.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Brigitte Tsutaoka
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC809 (FAS) - (06/04)
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