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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494042
Report Date: 11/06/2024
Date Signed: 11/06/2024 01:31:37 PM

Document Has Been Signed on 11/06/2024 01:31 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:CHAVEZ FAMILY CHILD CAREFACILITY NUMBER:
197494042
ADMINISTRATOR/
DIRECTOR:		CHAVEZ, LIZETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(747) 237-2454
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
11/06/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Lizette Chavez, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst’s (LPA) Dawn Dowling and Tatiana Bickham conducted an unannounced annual required inspection at the above facility on at 08:30 am. Upon arrival, LPA’s disclosed the purpose of the inspection and met with Lizette Chavez Licensee, 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. Also present was Jody Rubin, Licensee’s Assistant. There were ten day care children present during today’s inspection. Per Licensee, there are currently (eleven) children enrolled. Facility capacity is in compliance for a large Family Childcare Home. Hours of operation are Mon-Fri 07:30 AM to 5:30 PM.

LPA toured the home inside and outside. This is a detached “recreation” room (certificate of occupancy was posted), the backyard which includes a grass area and concrete cement area, and the bathroom in the recreation room are used for providing care and are accessible to children. detached storage shed and backyard (fenced).



Per Licensee, areas that are inaccessible to children include: The front yard, the attached garage, deck, the main house are off limits to the children in care. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises of the recreation room. Licensee stated there is a firearm and ammunition stored and locked separately in the main house. LPAs were unable to verify the storage of the firearm as it was not on the premises.

Licensee provides snacks. Parents provide packed lunch for children to bring to day care. Licensee reminded that food brought from home, it must be labeled with the child’s name and properly stored or refrigerated.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Dawn Dowling
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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: CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 197494042
VISIT DATE: 11/06/2024
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Individuals residing in the home have been discussed and noted. All adults present in the home have 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. The following was observed and reviewed during this inspection:

LPA's 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 on 09/16/2024.

Smoke and carbon monoxide detectors were observed, LPA’s were unable to test Smoke and Carbon monoxide detectors due to location of Smoke Detector and carbon monoxide Detectors (Located on ceiling that is high unable to reach). Fire extinguisher indicated fully charged and was purchased in 12/2023. The home maintains telephone service via land line and cell phone. The home is observed to be clean and orderly. There are toys and other age-appropriate materials available for children. LPA's did not observe Fireplace/open face heaters, No Staircase or stairs observed. LPA's observed that detergents, cleaning compounds and medication are stored in cabinet under 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 quiet book area or courtyard, away from the other children.

Infant care: Licensee currently does not have infants enrolled.

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's 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.


SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Dawn Dowling
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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: CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 197494042
VISIT DATE: 11/06/2024
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Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights.

Staff records were reviewed Licensee was missing Pediatric First Aid and Current CPR Certification; Assistant Missing Proof of Immunization's against MMR; T-Dap(Pertussis) and current Mandated Reporter Training Certificate.

— Pediatric First Aid and CPR expired: 03/11/2024
— Mandated Reporter AB1207 expired: 08/20/2024
___immunizations: MMR; T-Dap(Pertussis)

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):

This facility provides Incidental Medical Services- IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personal, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

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.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Dawn Dowling
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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: CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 197494042
VISIT DATE: 11/06/2024
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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's completed the RSO profile in FAS.

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

SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Dawn Dowling
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 01:31 PM - It Cannot Be Edited


Created By: Dawn Dowling On 11/06/2024 at 12:51 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: CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 197494042

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation,interview, record, and 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: 11/20/2024
Plan of Correction
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Licensee will email LPA proof of completing Pediatric CPR/First Aid Certificate 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:Dawn Dowling
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


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