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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192007666
Report Date: 05/02/2024
Date Signed: 05/02/2024 06:36:23 PM

Document Has Been Signed on 05/02/2024 06:36 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:RIVAS FAMILY CHILD CAREFACILITY NUMBER:
192007666
ADMINISTRATOR/
DIRECTOR:		RIVAS, ANTONIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 776-1396
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
05/02/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Antonia RivasTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
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On 5/2/24 at 9:38 am Licensing Program Analysts (LPA), Jeanine Lipsey conducted an announced Required 3 year Annual Inspection and was met by Licensee, Antonia Rivas. Entrance check list was provided. LPA observed one child licensee granddaughter and Licensee daughter. Days and hours of operation are Monday through Friday 8am to 5pm. Licensee does not have liability insurance. LPA discussed the LIC282 Affidavit Regarding Liability Insurance with applicant.

LPA Lipsey observed the following required postings: License, PUB 394 Notification of Parents’ Rights Poster, LIC 9148 Earthquake Preparedness Checklist LIC 610A and Emergency Disaster Plan.

LIC 9213 Notice of Site Visits shall be posted for 30 days after each site visit . LPA advised, any licensing report documenting a Type A citation must be posted for 30 days. LPA advised a disaster drill log shall be available with disaster drills completed at lease every six months. Licensee did not perform drills.

LPA toured all areas of the home. This is a 1 story, four bedroom, three bathroom home with living/dining room, kitchen and laundry room.

The areas that are accessible to children: are the living room, the playroom, bathroom, kitchen and the backyard for outdoor activities.

LPA observed any weed killer in the backyard sitting on metal shelf. The detergents, cleaning compounds, medication and other hazardous were accessible to children. Licensee will remove all hazardous items when children are present. Licensee will put a safety locks on the medicine, bathroom. kitchen and hall cabinets when children are in care. Per licensee, there are no firearms, or weapons on the premises. LPA did not observe any bodies of water on the premises.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 192007666
VISIT DATE: 05/02/2024
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LPA observed first aid kit to be missing xxxxxx. LPA Lipsey observed a non working carbon monoxide detector on the kitchen counter. LPA was not able to hear a successful test. Smoke detectors are located in the living room and hallway LPA was not able to hear a successful test. Fire extinguisher 2A10BC was observed, located on the wall of the kitchen, and was last serviced on 1/28/21. Licensee will have it serviced by 6/2/24. Electrical outlets were observed to be accessible to children in care, no plug covers present. The home was observed to be un-orderly in the playroom. Heating and ventilation was comfortable. LPA observed safe toys, play equipment, and materials. LPA verified the home has a working telephone service. There are no stairs in the home.

LPA observed the outdoor area to be fenced but not free from hazards. Licensee ensures that children in care are always supervised. Capacity as specified on the license is being maintained.

Licensee’s pediatric CPR/First Aid was expired. Licensee will retake the course in 2 weeks and send proof by 5/16/24. Mandated Reporter Training was expired. Licensee will retake the course by of 5/16/24 and send proof.

Licensee will provide LIC 9149 to the department by 5/16/24.

This home does not provide Incidental Medical Services – IMS. When a child is ill, they will be separated from the other children. Isolation area will be in the family room.

For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.

On this date, 5/2/24 the California Attorney General - Megan's Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.


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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 192007666
VISIT DATE: 05/02/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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-and­resources/safe sleep as an additional resource. LPA also informed licensee [or facility representative] 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.


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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 192007666
VISIT DATE: 05/02/2024
NARRATIVE
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and support staff completed the RSO profile in FAS.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, deficiencies are cited. Technical advisories discussed.

The following corrections are needed by due dates:

1. Applicant will purchase play yard for infant and send proof via email or text.


2. Licensee will retake CPR & Mandated reporter training in 2 weeks and send proof by 5/16/24 via email.
3. Licensee will remove shower gel/shampoo when children are in care.

4. Licensee will install safety lock on medicine cabinet and send proof by .

5. Licensee will have Fire extinguisher serviced by 6/2/24.

6. Licensee will provide proof of working smoke detectors and carbon monoxide by June 2, 2024.


7. Licensee will straighten up patio and play room and fix black pipe in back yard to prevent trip hazard and send proof by June 2, 2024.
8. Licensee will clean play toys and remove bricks by 6/2/24.
9. Licensee will lock outside storage area, and remove the hazard items from the garden area and send proof by 6/2/2024.
10. Licensee will remove the weed killer today.
11. Licensee does not have proof of drills, Licensee will provide proof of drill once children are present.
12. Licensee does not have proof of drills, Licensee will provide proof once children are present
13. Licensee is missing proof of measles, and TB shot. Licensee will provide proof by June 2, 2024.
14. Licensee is missing preventive health, practice, including pediatric cardiopulmonary resuscitation and pediatric first aid. Licensee will provide proof of training by July 2, 2024.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 192007666
VISIT DATE: 05/02/2024
NARRATIVE
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17. Licensee does not have proof of granddaughters immunization's, Licensee will provide proof by June 2, 2024.
18. Licensee did not maintain children's records with LIC 995A, Licensee will provide proof or records completed by June 2, 2024.
19. Licensee did not maintain emergency information card, Licensee will provide proof or records completed by June 2, 2024.
20. Licensee does not have current roster of children. Licensee will complete current roster by June 2, 2024.
21. Licensee does not have LIC 995A in the children's files. Licensee will provide proof when the bottom portion is signed in the file by June 2, 2024.
22. Licensee does not have copy of an affidavit stating the home does not carry liability insurance in the children's files. Licensee will provide proof by June 2, 2024.

LPA email: jeanine.lipsey@dss.ca.gov

Exit interview conducted and report was reviewed with the licensee Antonia Rivas.

A notice of site visit was given and advised Licensee that it must remain posted for 30 days.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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Page: 5 of 22
Document Has Been Signed on 05/02/2024 06:36 PM - It Cannot Be Edited


Created By: Jeanine Lipsey On 05/02/2024 at 04:28 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 192007666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, licensee failed to keep working carbon monoxide in the faculity which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2024
Plan of Correction
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Licensee will buy new a carbon monoxide detectors buy the due date and send proof of purchase by email. Jeanine.lipsey@dss.ca.gov
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above , licensee did not have locks on cabinets were cleaning compounds and detergents ae located which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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 Licensee will remove or place items high out of reach to children in care by due date.
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:Betty Bell
LICENSING EVALUATOR NAME:Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
Page: 6 of 22
Document Has Been Signed on 05/02/2024 06:36 PM - It Cannot Be Edited


Created By: Jeanine Lipsey On 05/02/2024 at 04:28 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 192007666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)(A)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, Licensee did not keep cabinets locked in bathroom and hall in which medicines and cleaning product is located, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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 Licensee will remove, place a lock or place items high out of reach to children in care by 5/9/24.
Type A
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above scissors attached to the refridgerator, on the living room table and on the tv stand, knives in the drawer under the stove, electrical plugs with no covers, bathroom with shower gell and shamppo in the shower, and cleaners underneath sink in the unlocked cabinets in the bathroom. Licensee will remove or place items high out of reach to children in care by. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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Licensee will remove or place items high out of reach to children in care, place plug covers and keep cabinet locked and send proof by email.
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:Betty Bell
LICENSING EVALUATOR NAME:Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
Page: 7 of 22
Document Has Been Signed on 05/02/2024 06:36 PM - It Cannot Be Edited


Created By: Jeanine Lipsey On 05/02/2024 at 04:28 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 192007666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation interview & record review, the licensee did not comply with the section cited above, licensee did not supply cabinet locks and plugs on eletrical outlets which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2024
Plan of Correction
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3
4
Licensee will retake training and send proof via email by due date.
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 observation interview &record review, the licensee did not comply with the section cited above Mandated reported training has expired which poses/posed a potential health, safety or personal rights risk to persons in care. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
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Licensee will retake training and send proof via email by due date.
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:Betty Bell
LICENSING EVALUATOR NAME:Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
Page: 8 of 22
Document Has Been Signed on 05/02/2024 06:36 PM - It Cannot Be Edited


Created By: Jeanine Lipsey On 05/02/2024 at 04:28 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: RIVAS FAMILY CHILD CARE
FACILITY NUMBER: 192007666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

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 observation interview & record review, the licensee did not comply with the section cited above Licensee does not have proof of measels an TB which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2024
Plan of Correction
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2
3
4
Licensee will send proof of immunizations via email by due date.
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
1
2
3
4
Based on observation interview & record review, the licensee did not comply with the section cited above, licensee did not have proof of health training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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2
3
4
Licensee will provide proof of training via email by due date.
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:Betty Bell
LICENSING EVALUATOR NAME:Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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