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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191806024
Report Date: 09/16/2021
Date Signed: 09/16/2021 04:12:29 PM

Document Has Been Signed on 09/16/2021 04:12 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:GOOSBY FAMILY CHILD CAREFACILITY NUMBER:
191806024
ADMINISTRATOR:GOOSBY, OLLIE MAEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
3233031521
CITY:LOS ANGELESSTATE: CAZIP CODE:
90007
CAPACITY: 12TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Ollie Mae Goosby, LicenseeTIME COMPLETED:
01:05 PM
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Prior to entrance to the facility, LPA Mayra Rivera conducted a Covid 19 assessment and based on the licensee responses to the facility assessment questions, LPA Rivera determined safe to proceed. On Wednesday, September 16, 2021 at 9:34 AM, Licensing Program Analyst (LPA) Mayra Rivera and LPA Lili Babcock conducted an unannounced annual inspection and met with Licensee Ollie Goosby who guided LPA Rivera and Babcock on a tour of the facility.

During the inspection, 2 children were present. LPA Rivera observed 2 children playing in the play room. Family members residing in the home has been discussed with licensee and are cleared. Operating hours are Monday to Sunday, 6:00 AM to 9:00 PM and care for children ages 0 to 12 years.

This facility is a two-story home that consists of five bedrooms, three bathrooms, kitchen, living room, dinning room, front and backyard (fenced and gated). Areas that are accessible to children and identified on the facility sketch were inspected by LPA Rivera; living room, dining room, bathroom daycare room and front/back yard.

Areas off limits to children include- second floor.

At approximately 9:35 AM LPA Rivera entered the facility to inspect for safety, comfort, cleanliness, ventilation and working phone. For ventilation, LPA Rivera observed AC/heater vents located towards the ceiling walls. LPA observed a cubby storage with children personal belongings and the furniture and children materials to be in good condition and age appropriate LPA observed safety gates in place to prevent children entering the kitchen, dinning and stairs.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: GOOSBY FAMILY CHILD CARE
FACILITY NUMBER: 191806024
VISIT DATE: 09/16/2021
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At approximately 11:10 AM, LPA Rivera entered the restroom and observed the toilet, and toilet paper. LPA observed the hand washing sink in the laundry room located next to the restroom. LPA observed running water, paper towels and hand soap. LPA observed the bottom cabinets closed and with a child proof lock in place making it inaccessible to children to open cabinet doors. LPA observed the restroom and hand washing sink to be in good condition.

At approximately 11:15 AM LPA observed cleaning compounds items stored inside the bottom kitchen sink and hand washing sink cabinets. LPA observed a child proof lock in place making it inaccessible to children to open the cabinets. Licensee understands that any poisons or firearms must be locked with a key or combination lock. For drinking water, LPA observed filtered water and licensee also uses bottle waters.

LPA Rivera asked if there are any pets, poisons, firearms, weapons or bodies of water. Licensee stated she has a turtle and no body of waters, firearms, weapons or poisons. LPA did not observe firearms, weapons, poisons nor bodies of water. Licensee was advised that if any poisons (ex; drano, rat poison or items with skull hazard symbol), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition must be stored separately.



At 10:58 AM LPA Rivera observed the required 2A10BC fire extinguisher located on the stairway and the valve on the green area indicating fully charged and serviced on 7/2/2021. LPA observed the smoke detector and carbon monoxide in the entry way and heard the sound of the detectors. The smoke and carbon detectors are in good condition.

At approximately 11:30 AM, LPA Rivera inspected the outdoor area for safety, comfort and cleanliness. Licensee informed LPA Rivera, children are currently not utilizing the backyard due to the lot adjacent to the backyard ongoing construction and not safe for children due to open dirt trough created by the construction. Licensee is currently using the front yard for play time. Licensee does not have an exact date of when the construction will be done. LPA advised to informed LPA as soon as the construction is done. LPA advised to place a mesh on the AC compressor to avoid children placing their fingers.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: GOOSBY FAMILY CHILD CARE
FACILITY NUMBER: 191806024
VISIT DATE: 09/16/2021
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LPA observed licensee Pediatric First Aid/ CPR certification with expiration date 7/2023. Licensee has proof of immunization against Pertussis, MMR and Influenza. Licensee has completed the mandated reporter (AB 1207) training on 6/22/21. Licensee was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com..

At approximately 10:21 AM LPA reviewed the children roster, and observed LIC 610A Emergency disaster plan, PUB 394 parents rights, emergency drill with last drill conducted on 8/2421.

At approximately 10:23 AM LPA reviewed licensee, child #1 and child #2 files. LPA issued the forms/records to keep in family child care home during the inspection. Child #1 is currently missing immunization's.


The following was discussed
INFANT CARE: LPA Rivera reviewed and discussed Safe Sleeping Practices information with licensee and a plan for supervising sleeping infants. LPA advised the licensee to sleep infants in an area where infants can be directly supervised. Place infants on their backs to sleep, on a firm mattress with fitted sheet that fits snugly in crib or play yard. LPA also advised against sleeping infants in a separate room with no direct supervision and no pillows, crib bumpers, swaddling, head covered, and pacifiers must not have anything attached. Safe sleep brochure was provided.

LPA Rivera also reviewed Sudden Infant Death Syndrome (SIDS), Never Shake A Baby, and Lead Exposure information with licensee. LPA also explained to licensee that car seat, stroller are only and only for transportation, highchair is only and only for feeding and stated items cannot be misused. No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into this category are not permitted in a family child care facility.



Medication: 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
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: GOOSBY FAMILY CHILD CARE
FACILITY NUMBER: 191806024
VISIT DATE: 09/16/2021
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LPAs advised the licensee how to access forms, regulations and quarterly updates , and Providers Information Notices (PIN) online at: www.ccld.ca.gov

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Licensee has been given a technical violation for Child # 1 missing immunization's. Exit interview was conducted and plans of correction were reviewed and developed with Licensee Ollie Goosby with due date October 1, 2021. A copy of this report and appeal rights were discussed and left with licensee, Ollie Goosby whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC809 (FAS) - (06/04)
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