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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197402666
Report Date: 06/07/2022
Date Signed: 06/07/2022 04:50:40 PM

Document Has Been Signed on 06/07/2022 04:50 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:FERNANDO FAMILY DAY CAREFACILITY NUMBER:
197402666
ADMINISTRATOR:FERNANDO, FEDRICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 717-0803
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Fedrica Fernando/LicenseeTIME COMPLETED:
03:45 PM
NARRATIVE
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On 06/07/22 Licensing Program Analyst (LPA) Silva Garibyan, conducted an unannounced Annual Required Inspection and was met by Licensee, Fedrica Fernando. Also present was Staff #1 (S1). Days and hours of operation are Monday – Friday from 7:00 AM to 6:00 PM .

LPA toured the home inside and outside and a census was taken. There were 5 preschool age children and two infants present at the time of the visit, Current facility sketch was reviewed. Facility is a two story home with 5 bedrooms and 3 bathrooms. Children in care have access to the lower level of the home only. Children in care have access to the living room, family room and kitchen. Primary child care if provided in the family room. Children have access to the bathroom to the right of the entry way to the home. The remainder of the home is off limits to children in care. All other rooms are off-limits and made inaccessible by use of safety gates. There is a swimming pool in the back yard. The pool has a five foot mesh fence surrounding the pool with a self - closing, self - latching gate. There are no firearms or ammunition on the premises. Firearms and ammunition are stored and locked separately. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The fireplace located in the living room is made inaccessible by a screen and will not be in use during daycare hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: FERNANDO FAMILY DAY CARE
FACILITY NUMBER: 197402666
VISIT DATE: 06/07/2022
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 Stairs are fenced or barricaded when children under age 5 years old are present. The home has working telephone service and LPA confirmed the phone number is (818) 717-0803.

There is two infants ( 16 and 23 months old) in care. LPA discussed Safe Sleep Regulations with licensee. There is one play yard for each infant in care. Play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

Licensee has a current roster of the children. An emergency fire/disaster drill has been completed and documented within the last 6 months. Licensee and assistant have not completed the Mandated Reporter Training. Licensee’s pediatric CPR/First Aid expires on 06/27/2023. Licensee was missing proof of immunization against influenza, pertussis, and measles for licensee and assistant.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: FERNANDO FAMILY DAY CARE
FACILITY NUMBER: 197402666
VISIT DATE: 06/07/2022
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Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/07/2022 04:50 PM - It Cannot Be Edited


Created By: Silva Garibyan On 06/07/2022 at 03:38 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: FERNANDO FAMILY DAY CARE
FACILITY NUMBER: 197402666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above in providing proof of completion the Mandated Reporter Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2022
Plan of Correction
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Proof of completion will be provided by POC Date.
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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Based on record review, the licensee did not comply with the section cited above in not having vaccinations available for review for licensee, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2022
Plan of Correction
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Licensee agrees to submit proof of vaccination to LPA via email for MMR, DTap and Flu vaccine and/or waiver for licensee and assistants.
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:Karren Starks
LICENSING EVALUATOR NAME:Silva Garibyan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


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