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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407231
Report Date: 11/18/2024
Date Signed: 11/18/2024 03:06:01 PM

Document Has Been Signed on 11/18/2024 03:06 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:GALLEGOS FAMILY CHILD CAREFACILITY NUMBER:
197407231
ADMINISTRATOR/
DIRECTOR:		GALLEGOS, VERONICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 626-9104
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 2DATE:
11/18/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Veronica GallegosTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Tatiana Bickham conducted an unannounced annual required inspection at the above facility on 11/18/2024 at 12:40 PM. Upon arrival, LPA disclosed the purpose of the inspection and met with Veronica Gallegos License, who guided LPA on a tour of the facility. Entrance Checklist – Family Child Care Homes LIC 126 was provided to the Licensee’s to help facilitate the inspection. There were (two) 2 day care children present during today’s inspection. Per Licensee, there are currently (seven) 7 children enrolled. Facility capacity is in compliance for a large Family Child Care Home. Hours of operation are Mon-Fri 6:00 AM - 8:00 PM.

LPA toured the home inside and outside. This is a one-story home which consists of 5 bedrooms, 2 bathrooms with kitchen/dining, living room, den(day-care room), detached garage (different address, rented to tenants), detached storage room, accessory dwelling unit (different address, rented to tenants), front yard and backyard (fenced).



Per Licensee, areas off limits to children and parents include: 4 bedrooms, front yard, detached garage, ADU and 1 detached storage room in the backyard.

Per Licensee, areas that are accessible to children include: Master bedroom and ensuite bathroom, living room, den, bathrooms 1 and 2, dining room, kitchen, and backyard. The bathroom that children use is located in the hallway adjacent to the living room and was observed to be clean and free of hazards.

Food is provided by Licensee. Licensee was reminded if children bring food from home, it must be labeled with the child’s name and properly stored or refrigerated.

Individuals residing in the home have been discussed and noted. All adults present in the home have
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SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GALLEGOS FAMILY CHILD CARE
FACILITY NUMBER: 197407231
VISIT DATE: 11/18/2024
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obtained a criminal record clearance or exemption.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. LPA reminded Licensee anytime they want to use rooms that were off limits to notify licensing and to submit an updated facility sketch. The following was observed and reviewed during this inspection:

LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted in October. LPA reminded Licensee to document on paper when the Disaster Drill is conducted.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged and was purchased within the year. The home maintains telephone service via cell phone. The home is observed to be clean and orderly. There are toys and other age-appropriate materials available for children. Fireplace is screened to prevent access by children. LPA observed that detergents, cleaning compounds and medication are stored in under the sink, inaccessible to children. Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in the living room or day-care room, away from the other children. Per Licensee there are no firearms or weapons stored in the home.

Infant Care: Currently licensee cares for 1 infant. LPA observed 3 cribs visible in the day-care room. Napping equipment does not block entrances or exits. Infant mattresses were observed to be firm with tightly fitted sheets. LPA did not observe loose object, bumpers, objects hanging, or objects attached to the cribs/play yards. There are currently no infants with pacifiers. Per licensee wet or soiled sheets are removed and washed. Each infant has their own crib and bedding. Bedding is washed weekly. LPA informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP. Licensee states the following sleep supervision plan for infants: Sit in the room with the children. Licensee informed Licensee that when the children are napping the door must remain open.

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SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
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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: GALLEGOS FAMILY CHILD CARE
FACILITY NUMBER: 197407231
VISIT DATE: 11/18/2024
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Overnight Care: Per Licensee no overnight care is provided.

Currently, children are using the back yard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that could be hazardous to children in care. There are no pools or spas, or other bodies of water.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunizations Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months)

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. Licensee did not have proof of immunizations and Pediatric CPR/First Aid expired 10/2024.

— Pediatric First Aid and CPR expires: 10/2024
— Mandated Reporter AB1207 expired: 7/2025

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful, and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

Incidental Medical Services (IMS): 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

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SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
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: GALLEGOS FAMILY CHILD CARE
FACILITY NUMBER: 197407231
VISIT DATE: 11/18/2024
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Licensee was reminded of their responsibility to report suspected child abuse. Mandatory Forms for the children’s files and provider’s files were discussed. Licensee was made aware that state law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category. Licensee was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. LPA also informed licensee 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. Licensee was also reminded that only children eating may be in highchairs and that car seats are utilized only for transportation.



Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

The licensee was advised 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, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. The applicant was made aware that a licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment.

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


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SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
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: GALLEGOS FAMILY CHILD CARE
FACILITY NUMBER: 197407231
VISIT DATE: 11/18/2024
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Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process. months)


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SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2024 03:06 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 11/18/2024 at 02:40 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: GALLEGOS FAMILY CHILD CARE
FACILITY NUMBER: 197407231

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee will sumbit an updated Facility Sketch to LPA by date listed above.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Raul Navarro
LICENSING EVALUATOR NAME:Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


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